Every finding on record at Alliance Health at Marina Bay

Based on records reviewed an interviews, for one of three sampled residents (Resident #1), who did not have an order for application of a hot pack for treatment of pain, the Facility failed to ensure services provided met professional standards of nursing practice related to obtaining a Physician's Order prior to administering a treatment, when on 05/23/26, Resident #1 complained of left lower extremity pain and nursing applied a disposable hot pack without contacting his/her Physician and without obtaining a Physician's Order, as required.Findings include:Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.Resident #1 was admitted to the Facility in May 2026 diagnoses include drug-induced myopathy (disease of the muscle tissue where fibers do not function properly leading to weakness, stiffness, or cramps), thyrotoxicosis (having too much thyroid hormone in your bloodstream), Parkinson's disease, and anxiety.During a telephone interview on 08/19/26 at 12:29 P.M., Resident #1 said that on 05/23/26, he/she had reported to the nurse (later identified as Nurse #1) that he/she was having some pain in his/her left lower leg and that he/she had requested a disposable hot pack for his/her pain.Resident #1 said Nurse #1 got his/her the disposable the hot pack, wrapped it in a pillowcase and placed it on his/her left lower leg for a short period of time.During a telephone interview on 08/19/26 at 3:49 P.M. Nurse #1 said she was Resident #1's assigned nurse on 05/23/26 from 7:00 A.M.-7:00 P.M. Nurse #1 said Resident #1 reported he/she was experiencing some left lower extremity pain and requested a hot pack.Nurse #1 said she assumed Resident #1 had a physician's order in place to provide a disposable hot pack to Resident #1's left lower extremity for comfort and had not checked his/her orders before getting the hot pack.Nurse #1 said she should have informed the physician of his/her lower leg pain complaint and should have obtained a physician's order prior to administering the disposable hot pack for Resident #1.During an interview on 08/19/26 the 3:04 P.M., the Unit Manager said she was not aware Resident #1 did not have a physician's order to receive a disposable hot pack for comfort. The Unit Manager said all nurses must obtain a physician's order prior to administering any treatment for all residents.During an interview on 08/19/26 at 3:36 P.M., the Director of Nurse (DON) said she was not aware Resident #1 had received a disposable hot pack for his/her complaint of left lower leg pain without Nurse #1 obtaining a physician's order.The DON said the Facility's expectation for all treatments, including the application of a disposable hot pack, the nurse must obtain a physician's order prior to providing the required treatment.On 08/19/26, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of 06/06/26) that addressed the area(s) of concern as evidenced by:1) 05/28/26, the Assistant Director of Nurses discovered that Nurse #1 had applied a disposable hot pack to Resident #1's left lower leg without obtaining a physician's order.2) 5/28/26, Resident #1 was assessed for pain, and the Physician was notified of the application of the disposable hot pack.3) 05/29/26, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held reviewing the incident and the IDT initiated a plan of correction.4) 05/29/26, a Facility wide audit was conducted by the Director of Nurses and/or designee identifying all residents that have a treatment for the use of a disposable hot pack. No other resident was identified as having utilized a disposable hot pack.5) 06/02/26, the Interdisciplinary Team (IDT) along with corporate insight, developed a Facility Policy for the proper use of disposable hot packs and other heat modalities.6) 06/02/26, Nurse #1 was educated and counseled on the Facility Policy for the need to obtain a physician's order with all treatments, including the use of disposable hot packs.7) On 06/02/26, the DON and Staff Development Coordinator (SDC) began education for all licensed nurses on the importance of obtaining a physician's order prior to performing any skilled treatment, including the application of disposable hot packs.8) 06/05/26, the DON and Unit Managers began weekly audits for four weeks, monthly for two months or until 100 % compliance is met ensuring all treatments provided have a physician's order.9) The Director of Nurse and/or designee is responsible for overall compliance.

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 three nurses observed during a medication pass made five errors out of 27 opportunities, resulting in a medication error rate of 18.52%. Specifically,1. For Resident #161, Nurse #3 prepared his/her medications, failed to identify the Resident and attempted to administer the medications to Resident #162; and,2. For Resident #93, failed to administer the correct does of Calcium plus Vitamin D; and3. For Resident #143, failed to administer the correct form of Vitamin B.Findings include:Review of the facility's policy titled Medication Administration-General Guidelines, last revised 1/2024, indicated but was not limited to:-Medications are administered as prescribed in accordance with good nursing principles and practices.-Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered.-A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: -When the medication is selected; -When the dose if removed from the container; and finally, -Just after the dose is prepared and the medication is put away.-Medications are administered in accordance with written orders of the prescriber.-Residents are identified before medication is administered using two methods of identification. Methods of identification include:-Checking photograph attached to medical record.-Calling resident by name (except in residents with cognitive impairment).-Having the resident verify his/her last name.-If necessary, verifying resident identification with other facility personnel.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.1. On 9/30/25 at 9:39 A.M., the surveyor observed Nurse #3 prepare the following medications for Resident #161:-Multivitamin 1 tablet-Vitamin D3 25 micrograms (mcg) 1 tablet-Metoprolol Succinate (used to treat high blood pressure) 25 milligrams (mg) 1 tabletNurse #3 entered Resident #161's room went over to Resident #162's bed and told him/her that he brought them their morning medications. Nurse #3 failed to check two forms of identification for Resident #162.Resident #162 asked Nurse #3 what medications they were receiving.Nurse #3 told Resident #162 he/she was receiving two vitamins and a blood pressure medication. Resident #162 asked Nurse if he/she was going to get their Haldol (an antipsychotic medication).Nurse #3 exited the room and reviewed the medications for Resident #161. He looked at the surveyor and said he did not see Haldol on their medication list.The surveyor asked Nurse #3 if he had intended to administer medication in the medication cup to Resident #162. Nurse #3 said yes, he was.The Surveyor asked Nurse #3 to verify whom he had prepared the medications for. He said he had prepared the medications for Resident #161.The surveyor asked Nurse #3 to verify the name of the Resident he had prepared the medications for again. The surveyor asked Nurse #3 to look at the name on the Medication Administration Record (MAR). Nurse #3 looked at the name on the MAR and asked the surveyor if he messed up. Nurse #3 then said he prepared the medications for Resident #161 not Resident #162.During a follow-up interview on 9/30/25 at 11:29 A.M., Nurse #3 said when administering medication, you must identify the resident who you are administering medication to. He said he had not verified the resident to whom he to attempted to administer medication to.During an interview on 9/30/25 at 11:42 A.M., the Director of Nursing (DON) said Nurse #3 should have followed the Five Rights when administering medications and should have used two identifiers to identify the correct resident.2. On 9/30/25 at 10:06 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #143 including:-Vitamin B12 Complex (a supplement containing the eight essential B vitamins (B1-B12) that support energy metabolism, nerve function, and red blood cell production)Review of Resident #143's Physician's Orders indicated but was not limited to:-Vitamin B-12 (a vitamin used for keeping nerve and blood cells healthy, and for making DNA) 500 mcg, give one tablet daily, dated 9/16/25During an interview on 9/30/25 at 10:27 A.M., Nurse #2 reviewed Resident #143's physician's orders and said she had administered the wrong form of Vitamin B-12 to Resident #143 and should have verified the order prior to administering the medication.3. On 9/30/25 at 8:16 A.M., the surveyor observed Nurse #4 prepare and administer medications to Resident #93 including:-Calcium 600mg + Vitamin D3 10 mcg (400 units)Review of Resident #93's Physician's Orders indicated but was not limited to:-Calcium 600mg +Vitamin D3 5mcg (200 units), give 1 tablet twice daily, dated 9/19/25During an interview on 9/30/25 at 12:02 P.M., Nurse #4 said she had grabbed the wrong bottle this morning and should have verified the dose prior to administering the medication.During an interview on 9/30/25 at 11:42 A.M., the DON said when the nurses were preparing medications, they must follow the 5 Rights and verify that they were preparing and administering the correct medication and the correct dose of the medication.

Based on record review, observation, and interviews, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#131) with an unplanned weight loss, out of a total sample of 30 residents. Specifically, the facility failed for Resident #131 to implement dietary recommendations/interventions after weight loss had been identified, and he/she continued to lose weight. Findings include: Review of the facility's policy titled Consultant Dietician, dated as last revised 11/1/2021, indicated but was not limited to the following:-The consultant Dietician has weekly regular hours of sufficient duration to provide consultation to staff regarding Residents' dietary needs and assistance with the revision and implementation of Nutritional Policies and Procedures.-The Registered Dietician (RD) will provide a comprehensive report to the Executive Director and the Director of Nurses (DON) following each visit. Resident #131 was admitted to the facility in September 2024 with diagnoses which included B-cell lymphoma and diabetes mellitus. Review of the Minimum Data Set (MDS) Assessment, dated 7/17/25, indicated Resident #131 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. Additionally, the MDS indicated unknown/no for weight loss of 5% or 10% in the last six months. During an interview on 9/26/25 at 10:00 A.M., Resident #131's daughter said Resident #131 had been losing weight, was not eating, and needed assistance with feeding. She said he/she did not eat breakfast again today, and she requested staff help with feeding every meal as he/she is not eating and has difficulty with the utensils. On 10/1/25 at 9:15 A.M., the surveyor observed Resident #131 lying in bed asleep with a breakfast tray in front of them, uncovered, with food untouched, no staff was present offering assistance. Review of the Physician's Orders and Medication Administration Record (MAR) indicated but was not limited to the following:-No Added Salt (NAS), Diabetic (HCC) regular with thin liquid at Breakfast, Lunch, and Dinner (9/26/24) Review of the medical record indicated gradual weight loss over the last year. Specifically, the weight record indicated:-10/2/24: 186.6 pounds (lbs.)-3/31/25: 161.6 lbs. (down 13.4% in 6 months)-9/30/25: 150.5 lbs. (down another 7.18% in 6 months and 19.35% in 12 months) Review of the Dietary progress notes indicated but were not limited to the following:-4/30/25: late entry for week prior: significant weight loss since admission, could liberalize diet some, could offer Mighty Shake (calorie and protein fortified shake) once a day at supper.-8/16/25: weight loss 5.5% in six months, continues HCC, NAS Diet, does not like meals, agreed to have Magic Cup (calorie and protein fortified ice cream) two times daily, recommend Multivitamin with Mineral for overall health and Magic Cup twice a day.-9/24/25: Weight trending down again, 151 lbs. this week, would liberalize diet and could offer Glucerna (Diabetic fortified drink) supplement between meals.-9/30/25: 6.7% weight loss in six months, Recommend liberalizing diet to House related to slow weight loss and desire to eat, notified kitchen. Recommend Multivitamin with Minerals and add magic cup twice daily. Review of the Diet order failed to indicate the diet had been liberalized. Review of the Diet and Physician's orders failed to indicate Mighty Shake, Magic Cup, Multivitamin with Minerals, or Glucerna had been ordered/implemented. Review of the nursing and physician progress notes failed to indicate the RD recommendations had been reviewed and declined by the physician. During an interview on 10/2/25 at 11:53 A.M., Nurse #7 said dietary recommendations should be in the paper medical record. He said the RD writes and flags them for the nurse to get approved by the physician. He said there were not any dietary orders/recommendations since January 2025 in his/her record. During an interview on 10/2/25 at 12:52 P.M., Unit Manager #4 said the RD emails recommendations and then nursing writes the orders. She said she doesn't always get the email, the reports are not consistent, and communication is difficult. She said the previous RD would write the orders, flag them in the medical record, and then the nurse would get the order approved by the physician. She said now there are three or four RDs and it is confusing. She said when she does get the email, they are long, as it is for the entire building. She said she did not have an email to correlate with the 4/30/25, 8/16/25, or the 9/24/25 RD notes. She said she found one from 4/23/25 and one from 10/1/25 that referenced Resident #131. Review of the 4/23/25 RD email with recommendations indicated a recommendation to discontinue current diet and start HCC, No Salt Packet. Review of the medical record including physician orders/MAR and progress notes failed to indicate the Diet change had been implemented or that the physician declined the recommendation. During an interview on 10/2/25 at 12:52 P.M., Unit Manager #4 said she did not have an email dated 4/30/25 regarding the Mighty Shake, dated 8/16/25 regarding the Magic Cup and Multivitamin, or dated 9/24/25 regarding liberalizing the diet or the Glucerna. Additionally, she said she had not read the 10/1/25 email yet. Review of the 10/1/25 RD email with recommendations indicated a recommendation to liberalize Diet to House, patient not eating. Orders need updated: Magic Cup is on order list please. Please visit Resident #131, does not like meals, please see to help with menu choices. The 10/1/25 RD email failed to include the repeated recommendation for a Multivitamin with Minerals as noted in the RD progress notes dated 8/16/25 and 9/30/25. Review of the medical record including physician orders and progress notes failed to indicate the Diet change, the Magic Cup, or Multivitamin with Minerals had been implemented or that the physician declined the recommendations. During an interview on 10/2/25 at 2:38 P.M., the DON said the RD emails the recommendations for the Unit Manager to write the orders. She said the system is confusing as they get so many emails and it clearly is not working if the recommendations made in the progress note do not match the email and the recommendations are getting missed and not ordered. During an interview on 10/2/25 at 3:18 P.M., RD #1 said at the end of every day they (the RDs) send an email report with all the findings, recommendations, and tray card changes. She said the report has information from the visits and eval/assessments done that day. She said the report is not generated from the eval/assessment or their progress note. She said they must type it all again. The surveyor reviewed the RD progress notes and emails with RD #1. RD #1 said the 4/30/25 email should have had the Mighty Shakes on it, and it did not. She said she had an email from 8/16/25, but those recommendations were never implemented, and they did not match what was written in the progress note. RD #1 said the 9/24/25 progress note indicated the same August recommendations were again repeated. She was unable to provide an email regarding this visit and said she should have caught the fact the recommendations were being repeated and had not been implemented. She said the diet change and Magic Cup recommendations were repeated on 9/30/25, are in the 10/1/25 email, but have not been done yet, but the Multivitamin recommendation was not included in the email. She said there must be a better system to communicate recommendations because we are missing things from the notes to the emails, and the orders are not getting implemented from the emails.

Based on record review and interview, the facility failed to develop and implement a person-centered care plan for the use of psychotropic medications for one Resident (#163), out of a total sample of 30 residents. Specifically, the facility failed for Resident #163 to ensure a care plan had been developed for the use of Ativan/Lorazepam (anti-anxiety medication), to monitor for adverse effects/side-effects of the medication, and to monitor for targeted behaviors. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Planning, dated as last revised 9/22/22, indicated but was not limited to the following:-The facility is required to develop a comprehensive person-centered care plan for each resident that is consistent with resident rights and includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs.-Reviewed and revised by the interdisciplinary team, after each assessment, including comprehensive and quarterly review assessments. Review of the facility's policy titled Psychotropic Medication Management, dated as last revised 4/28/25, indicated but was not limited to the following:-A Psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors, including anti-anxiety drugs.-Ensure supportive diagnosis and target behaviors are documented.-Monitor target behaviors daily using a behavior monitoring tool-Care plan the psychotropic medication use, supportive diagnoses, goals of therapy, target behaviors, and pharmacological and non-pharmacological approaches, inclusive, but not limited to behavioral interventions. Resident #163 was admitted in August 2023 with diagnoses which include senile adjustment disorder with anxiety and insomnia. Review of the Minimum Data Set (MDS) Assessment, dated 9/23/25, indicated he/she scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she had moderate cognitive impairment, and he/she had not received Anti-Anxiety medications during the review period. Review of the Comprehensive Care Plan failed to indicate he/she was taking psychotropic medication, to monitor for adverse effects/side-effects of the medication, and to monitor for targeted behaviors. Review of the active Physician's Orders indicated but were not limited to the following:-May continue Ativan x 14 days then reassess (9/27/25) (anti-anxiety medication) Review of the Medication Administration Records (MAR) from September 2025 through October 2025 indicated but were not limited to the following:-Lorazepam 0.5 milligrams (mg) every 4 hours as needed (PRN) (9/13/25-9/26/25)-Lorazepam 0.5mg every 4 hours PRN (9/26/25-9/27/25)-Lorazepam 0.5mg every 4 hours PRN (10/2/25-10/16/25) The physician's orders failed to indicate to monitor for adverse effects/side-effects of the medication or to monitor for targeted behaviors. During an interview on 10/2/25 at 11:53 A.M., Nurse #7 said there was not a care plan, but there should be. Additionally, he said the behavior monitoring and side effect monitoring should be on the MAR, and they were not. During an interview on 10/2/25 at 12:52 P.M, Unit Manager #4 said there should be a care plan in place and there was not one. She said they have a psychotropic medication template and then it should be personalized. She said the target behavior and side effect monitoring should be on the MAR and they were not. During an interview on 10/2/25 at 2:38 P.M., the Director of Nurses (DON) said the targeted behaviors and side effect monitoring should be on the MAR and they were not. She said the certified nursing assistants document to regular behavior sheets, but the nurses document the targeted behaviors for the psych meds on the MAR. Additionally, she said Resident #163 did not have a care plan in place and he/she should have one.

Based on interview and record review, the facility failed to assess and develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#160) with a history of trauma, out of a total sample of 30 residents.Findings include: Review of the facility's policy titled Trauma Informed Care Program, revision date 10/16/22, included but was not limited to the following:-Procedures: residents will be screened for past trauma and for signs/symptoms of traumatic stress upon admission, quarterly, annually, and as needed. -If the result of the screen indicates the presence of trauma or traumatic stress, further assessment will be completed. The interdisciplinary team, in collaboration with the resident and with the approved resident's representative will create a culturally sensitive plan of care to help prevent re-traumatization and to optimize quality of life. Individualized resident triggers will be identified as able.-These plans of care shall include the identified trigger, prevention, intervention, and treatment services that address traumatic stress. Resident #160 was admitted to the facility in July 2025 with diagnoses including post-traumatic stress disorder (PTSD).Review of Resident #160's Minimum Data Set (MDS) assessment, dated 7/9/25, indicated he/she had a moderate cognitive impairment as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS).On 9/29/25 at 11:37 A.M., the surveyor observed Resident #160 in the dining room sitting in his/her wheelchair. The surveyor observed two other residents sitting at the opposite end of the table from Resident #160, one resident put their fist on the table repeatedly which resulted in a loud noise. Resident #160 attempted to stand up from their wheelchair and said, I don't like loud noises. Immediately following this observation, the surveyor witnessed another resident yelling out loudly and Resident #160 appeared startled and attempted to stand up from his/her wheelchair and said, stop yelling. Review of Resident #160's nursing progress notes, dated 7/10/25, indicated but was not limited to:-Resident kept saying everyone will die tonight and kept praying. This writer and CNA (Certified Nursing Assistant) kept the Resident on 1:1 supervision as he/she always tries to get up when he/she doesn't see someone looking over them inside the room.-Resident #160 had increased anxiety stating the explosion is going to happen soon. Review of Resident #160's medical record and assessments since admission failed to indicate he/she was assessed for their trauma including triggers and mitigation techniques and an assessment had been completed.Review of Resident #160's care plan failed to indicate a care plan had been established related to potential trauma and triggers were identified. During an interview on 10/1/25 at 8:56 A.M., Nurse #5 said she was aware the Resident was in the Army but didn't have any additional psychosocial information. She said the Resident can be combative with care, had periods of anxiety and agitation, and attempts to self-rise from his/her wheelchair if startled. She said she never thought about if his/her time in the Army contributed to his/her behavior or reactions to loud noises.During an interview on 10/1/25 at 2:35 P.M., Social Worker#1 said trauma assessments should be completed within 72 hours of admission. He said he was aware Resident #160 had served in the military and had a diagnosis of PTSD. He reviewed Resident #160's medical record and said a trauma assessment had not been completed for him/her. He said he had not completed Resident #160's trauma assessment or attempted to identify any triggers for him/her but should have.During an interview on 10/1/25 at 3:02 P.M., the Administrator said the expectation was for every resident to have been assessed for trauma, and she expected triggers to be identified and mitigation techniques established for a resident with PTSD.

Based on observation and interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure for Resident #163 that staff performed hand hygiene and donned (put on) gloves and/or used utensils while handling ready to eat food during breakfast service/meal preparation. Findings include:Review of the Food and Drug Administration (FDA) Food Code 2022 indicated:3-301 Preventing Contamination by Employees3-301.11 Preventing Contamination from Hands.(A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. Review of the facility's policy titled Proper Food Preparation, dated as last revised 9/1/24, indicated but was not limited to the following:-All foods will be prepared in a manner to prevent cross-contamination.-Food will be handled as little as possible.-Plastic gloves and utensils will be used in the production and serving of all foods. Resident #163 was admitted to the facility in August 2023 with diagnoses which include dysphagia (difficulty swallowing), legal blindness, and macular degeneration right eye. Review of the Minimum Data Set (MDS) Assessment, dated 9/23/25, indicated he/she scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Additionally, he/she had moderate vision impairment, macular degeneration, and was legally blind. During an interview on 9/26/25 at 9:20 A.M., Resident #163 said they could not see well and did not know how they were supposed to eat the large biscuit, as it was hard and dry. During the interview, the Speech Therapist entered the room and Resident #163 asked her how he/she was supposed to eat the large biscuit. Should it be cut in half or just bite it? Resident #163 restated that it was big, hard, and dry. On 9/26/25, the surveyor observed the following:-At 9:20 A.M., the Speech Therapist picked up the biscuit from the plate with her bare hands, and while holding it, asked Resident #163 if they wanted some butter or jam to put on it. Resident #163 said that might help. The Speech Therapist put the biscuit back down on Resident #163's plate and wiped her hands off with a dry tissue from Resident #163's overbed table and exited the room to get butter and jam. -At 9:23 A.M., the Speech Therapist returned with butter and jam packets. She picked up the biscuit from the plate, using her bare hands, pushed her fingers into the biscuit and pulled the biscuit apart into two halves. The Speech Therapist proceeded to hold the biscuit halves in the palm of her bare hand and applied butter and jam with a knife to the biscuit. After placing the knife down, she touched the cups and utensils on the breakfast tray, and then the bed sheet, before she handed Resident #163 the biscuit and wiped her hands off with a dry tissue from Resident #163's overbed table. During an interview on 10/2/25 at 12:52 P.M., Unit Manager #4 said no food should be handled with bare hands. She said if something like a roll or biscuit need to be picked up, it should be done with gloves on or with the silverware. During an interview on 10/2/25 at 2:38 P.M., the Director of Nurses (DON) said if staff need to pick up food to assist with preparation, they should have gloves. She said they should never handle food with bare hands.

Based on record review and interview, the facility failed to implement written policies and procedures for an allegation of abuse for one Resident (#5), out of a total sample of 30 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of abuse was documented and reported on 5/1/25. Findings include:Review of the facility's policy titled Abuse Prohibition, last revised 10/11/22, indicated but was not limited to:-The facility will provide an environment in which the resident is free from abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, including but not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the resident's medical symptoms.-Identifying events, occurrences, patterns, and trends of potential abuse for residents.-Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of the same to proper authorities.-Protecting residents from harm during an investigation of alleged abuse.-Reporting of all alleged violations of resident abuse to appropriate state agencies utilizing the proper online reporting system with the simultaneous development of corrective actions determined as part of the internal facility investigation to prevent further occurrences of abuse.- It will be the facility's responsibility to identify, correct, and intervene in situations where Abuse, Mistreatment, Neglect, Exploitation, Harm, Willful Acts and/or Misappropriation of Resident Property occur.-The following require an incident report, supervisory follow-up and a comprehensive internal facility investigation which shall be performed with subsequent timely notification to the appropriate agencies as warranted.-Abuse/Potential Abuse -Willful infliction of injury (physical abuse) -Intimidation (Verbal Abuse)-Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or assault and battery. This presumes that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.-Willful: 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 derogatory terms to residents or their families.-Mental: includes humiliation.-Any incidents of actual suspected abuse must have an incident report completed in addition to the incident report the supervisory personnel are responsible to ensure that the internal investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm.-These interventions will include the obtaining of statements from witnesses of incidents, the outcome of the supervisory investigation and the timely notification of administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion and appropriate staff interventions are included in the resident's comprehensive plan of care.-The executive director shall assume the overall responsibility to ensure that incident reports are accurately completed and personnel statements are obtained timely to ensure proper completion of the internal facility investigation. The executive director shall ensure that the appropriate agencies are notified in writing as warranted of abuse allegations in all investigatory findings by utilizing the state documentation tool. The initial report shall be submitted to the department immediately but not later than two hours after the allegation is made. A final report will be submitted to DPH within five business days of the incident. If alleged violation is verified, appropriate corrective action will be taken.-All alleged violations of incidents included within the definition of abuse, mistreatment, neglect, involuntary seclusion or misappropriation of resident property shall be reported to the Department of Public Health, Division of Health Care Quality upon receipt of the facility's report of basic findings. The facility must then begin an internal investigation of the incident. Resident #5 was admitted to the facility in March 2025 with diagnoses of cerebral infarction (stroke) and aphasia (a language disorder that can occur after a stroke, affects a person's ability to communicate, including speaking). Review of the Minimum Data Set (MDS) assessment, dated 7/4/25, indicated Resident #5 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and was non-verbal but able to make himself/herself understood and he/she was able to understand others. Review of Resident #5's progress note, dated 5/1/25 at 2:10 P.M., written by Nurse #1, indicated but was not limited to:Witnessed on several occasions Resident's roommate being indirectly very verbally abusive to the Resident. Stating out loud when Resident requests to go back to bed that of course he/she does, he/she just wants to lay there like a lump and do nothing He/she just lays there and sh**s the [expletive] bed, and I have to sit here and smell it. His/her family member comes in and screws up the TV every time. He/she leaves the [expletive] TV on all night, and I can't sleep. Resident in ear shot with all of these comments with eyes bulging as if scared. I witnessed this behavior again today. Resident pointed at roommate and made a hand gesture as if talking then pointed at himself/herself. I asked him if his/her roommate was yelling at him. He/she nodded yes. When roommate was out of the room I spoke with Resident and acknowledged that these comments seemed to very much upset him/her. He/she nodded yes. Nurse #1 offered him/her if another room was available would he/she like to be moved. He/she wrote down on notepad I'd move. Nurse manager made aware and was trying to get in touch with the Health Care Proxy for approval. Review of the Health Care Facility Report System (HCFRS, a system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 9/29/25 failed to indicate the facility reported the incident to the state agency. During an interview on 10/21/25 at 11:18 A.M., Nurse #1 said Resident #5 had a room change in May related to a roommate issue. Nurse #1 reviewed the note she had written on 5/1/25 and said Resident #142 had indirectly and directly verbally abused Resident #5. She said Resident #142 would get anxious and take their anxiety out on Resident #5. Nurse #1 said this was not the first time Resident #142 made comments to or about Resident #5. She said Resident #5 was alert and she could tell by his/her facial expressions that he/she would become scared and/or upset by Resident #142's comments. She said she would ask Resident #5 if he/she was scared or upset and he/she would nod yes. She said she reported the incident from 5/1/25 to the Director of Social Service and to the Unit Manager. During an interview on 10/1/25 at 11:28 A.M., the Director of Social Service said Resident #5 would communicate/answer questions by nodding or shaking their head to answer yes/not questions or would write down information on a pad of paper. He reviewed the note dated 5/1/25 and said in a situation like this where there was no immediate danger to the residents, the facility would offer the resident a room change which was made for Resident #5. He said Resident #5 was offered a room change because his/her roommate was being loud towards them. He said he followed up with Resident #5 after the room change and he/she said they were relieved because there would be no more yelling toward him/her. He said Resident #142 did not speak to Resident #5 like this every day but intermittently, it had only happened maybe two times prior to the 5/1/25 incident. He said any incident of abuse or alleged abuse needed to be reported to the Administrator or Director of Nursing and an investigation initiated. He said this incident would not be considered a resident-to-resident altercation because it had only happened intermittently and sometimes roommates just do not get along. He reviewed Resident #5's medical record and said he had not written a note regarding the incident that occurred on 5/1/25 but did write a note on 5/6/25 as follow-up to Resident #5 room change. Review of Resident #5's medical record indicated he/she had a room change on 5/2/25. During an interview on 10/1/25 at 11:46 A.M., the Administrator said any incidents of abuse or alleged abuse needed to be reported in HCFRS within two hours unless an investigation concluded that abuse had not occurred. She reviewed the note Nurse #1 wrote on 5/1/25 and said in an incident like this the facility would offer the Resident a room change and remove them from the situation. She said if the facility had thought the incident that occurred on 5/1/25 was considered abuse then it would have been reported in HCFRS, and investigation would have been initiated immediately. The surveyor asked the Administrator if this incident was considered abuse because Resident #5 was upset by the situation and was scared of Resident #142. She asked the surveyor to return later so she could follow up with the team. During a follow-up interview on 10/1/25 at 2:11 P.M., the Administrator said she followed up with the Director of Social Services and he was involved with the incident that day. She said the incident was discussed the next day in morning meeting. She said when the Director of Social Services followed up with Resident #5 after the incident he/she was in a pleasant and calm mood. She said she could not provide the surveyor with an investigation because the facility had not considered this incident as abuse, and the incident did not rise to the level of an investigation but if it had then the facility would have followed their policy. Review of Resident #5's medical record on 10/1/25 at 3:00 P.M., indicated the Director of Social Service had written a late entry note in Resident #5's medical record on 10/1/25 at 12:46 P.M, regarding the incident which occurred on 5/1/25. During an interview on 10/2/25 at 1:31 P.M., the Staff Development Coordinator said any incident of alleged abuse must be reported immediately and an investigation must be initiated to determine if the alleged abuse occurred or not. On 10/2/25 at 2:12 P.M., the Director of Nursing said the Director of Social Services spoke with Resident #5 and at that time Resident #5 said he was not afraid of Resident #142. She said Resident #142 was a nice person and had not threatened Resident #5. She said the facility started an investigation but determined abuse had not occurred when the Director of Social Services spoke to Resident #5. She said in the facility's mind the incident that occurred between Resident #5 and Resident #142 was not abuse. At the time of exit the facility did not provide the survey team with an investigation of the incident between Resident #5 and Resident #142. Refer to F609

Based on record review and interviews, the facility failed to report an allegation of abuse to the state agency for one Resident (#5), out of a total sample of 30 residents.Findings include:Review of the facility's policy titled Abuse Prohibition, last revised 10/11/22, indicated but was not limited to:-Reporting of all alleged violations of resident abuse to appropriate state agencies utilizing the proper online reporting system with the simultaneous development of corrective actions determined as part of the internal facility investigation to prevent further occurrences of abuse.-The executive director shall assume the overall responsibility to ensure that incident reports are accurately completed and personnel statements are obtained timely to ensure proper completion of the internal facility investigation the executive director shall ensure that the appropriate agency agencies are notified in writing as warranted of abuse allegations in all investigatory findings by utilizing the state documentation tool the initial report shall be submitted to the department immediately but not later than two hours after the allegation is made a final report will be submitted to DPH within five business days of the incident if alleged violation is verified appropriate corrective action will be taken.-All alleged violations of incidents included within the definition of abuse, mistreatment, neglect, involuntary seclusion or misappropriation of resident property shall be reported to the Department of Public Health, Division of Health Care Quality upon receipt of the facility's report of basic findings. The facility must then begin an internal investigation of the incident. Resident #5 was admitted to the facility in March 2025 with diagnoses of cerebral infarction (stroke) and aphasia (a language disorder that can occur after a stroke, affects a person's ability to communicate, including speaking).Review of the Minimum Data Set (MDS) assessment, dated 7/4/25, indicated Resident #5 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and was non-verbal but able to make himself/herself understood and he/she was able to understand others.Review of Resident #5's progress note, dated 5/1/25 at 2:10 P.M., written by Nurse #1, indicated but was not limited to:Witnessed on several occasions Resident's roommate being indirectly very verbally abusive to the Resident. Stating out loud when Resident requests to go back to bed that of course he/she does, he/she just wants to lay there like a lump and do nothing He/she just lays there and sh**s the [expletive] bed, and I have to sit here and smell it. His/her family member comes in and screws up the TV every time. He/she leaves the [expletive] TV on all night, and I can't sleep. Resident in ear shot with all of these comments with eyes bulging as if scared. I witnessed this behavior again today. Resident pointed at roommate and made a hand gesture as if talking then pointed at himself/herself. I asked him if his/her roommate was yelling at him. He/she nodded yes. When roommate was out of the room I spoke with Resident and acknowledged that these comments seemed to very much upset him/her. He/she nodded yes. Nurse #1 offered him/her if another room was available would he/she like to be moved. He/she wrote down on notepad I'd move. Nurse manager made aware and was trying to get in touch with the Health Care Proxy for approval.Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 9/29/25, failed to indicate the facility submitted a report on 5/1/25 for an allegation of abuse.During an interview on 10/1/25 at 11:46 A.M., the Administrator said any incidents of abuse or alleged abuse needed to be reported in HCFRS within two hours unless an investigation concluded that abuse had not occurred. She said if the facility had thought the incident that occurred on 5/1/25 was considered abuse then it would have been reported in HCFRS, and investigation would have been initiated immediately. The surveyor asked the Administrator if this incident was considered abuse because Resident #5 was upset by the situation and was scared of Resident #142. She asked the surveyor to return later so she could follow up with the team.During a follow-up interview on 10/1/25 at 2:11 P.M., the Administrator said the incident from 5/1/25 was discussed the next day during morning meeting on 5/2/25 and the facility had not considered the incident as abuse and had not reported it in HCFRS.

Based on observation, record review, 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 and date food products, and to maintain safe and clean equipment in four of five nourishment kitchenettes. Findings include: Review of the facility's policy titled Food & Nutrition Services, revised 12/5/21, indicated but was not limited to the following: - Food brought in by family or visitors will be in a secure container/bag, dated and will be subject to disposal based on sanitary, safe consumption. - If there are leftovers, the Facility will label the leftovers and store them in accordance with the Facility's policies for use and storage of foods, including but not limited to, policies relating to food sanitation. On 9/17/24 at 9:09 A.M., the surveyor made the following observations on the Cityside Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food splatter covering the sides and top portion. - The refrigerator had a gallon size resealable bag with red grapes, dated 9/15/24, but no resident identification. - The refrigerator had two containers of soup wrapped in a plastic bag with no date or resident identification. On 9/17/24 at 3:44 P.M., the surveyor made the following observations on the Harborside One Unit nourishment kitchenette: - The inside of the microwave had brown food residue on the glass plate. The top portion of the microwave had peeling white plastic and burnt/bubbling plastic revealing the metal component underneath. - The refrigerator had a Styrofoam container on the bottom shelf with no date or resident identification. On 9/17/24 at 3:52 P.M., the surveyor made the following observations on the Harborside Two Unit nourishment kitchenette: - The inside of the microwave had a paper towel covering the glass plate with food residue. There was food splatter/stains covering the top and side of the microwave. - The freezer contained a Hershey's candy bar with no date or resident identification. On 9/18/24 at 8:04 A.M., the surveyor made the following observations on the Seaport Unit nourishment kitchenette: - The inside of the microwave had food residue/splatter on the top and sides. The top portion of the microwave had peeling white plastic and burnt/bubbling plastic revealing the metal component underneath. On 9/18/24 at 1:31 P.M., the surveyor made the following observations on the Harborside One Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food splatter covering the sides and top portion. On 9/18/24 at 1:35 P.M., the surveyor made the following observations on the Harborside Two Unit nourishment kitchenette: - The inside of the microwave had a paper towel covering the glass plate with food residue. There was food splatter/stains covering the top and side of the microwave. On 9/18/24 at 1:40 P.M., the surveyor made the following observations on the Cityside Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food splatter covering the sides and top portion. During an interview on 9/18/24 at 2:08 P.M., Dietary Staff #2 said she was in charge of stocking dietary items, including snacks and drinks, on each of the units nourishment kitchenettes every morning. Dietary Staff #2 said the Housekeeping staff is responsible for keeping nourishment kitchenettes clean, including microwaves and refrigerators. During an interview on 9/19/24 at 9:57 A.M., Housekeeping Staff #1 said she is typically responsible for cleaning the rooms and dining area on the Cityside Unit. Housekeeping Staff #1 said when cleaning the room, she makes sure the floors are clean and equipment like microwaves and refrigerators are also cleaned. During an interview on 9/19/24 at 10:25 A.M., the Dietitian said refrigerators and microwaves in the unit nourishment kitchenettes are to be for resident use only. The Dietitian said the microwaves on each unit should be cleaned appropriately and in good working condition. The Dietitian said food items left in the refrigerators in the unit nourishment kitchenettes should be labeled with the resident name and/or room number and dated.

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made seven errors out of 40 opportunities, totaling a medication error rate of 17.5%. These errors impacted one Resident (#14), out of three residents observed. Specifically, the nurse administered the wrong dose of Buspar (for anxiety), Neurontin (for seizures or nerve pain), and Tylenol (for mild to moderate pain), and failed to administer Anoro Ellipta (inhaler for lung conditions), Fluticasone Propionate (inhaler for lung conditions), Ipratropium Bromide (aerosol for lung conditions), and Lidocaine patches (local anesthetic for pain management) as ordered. Findings include: Review of the facility's policy titled Administration Procedures for All Medications, dated as last revised 2024, indicated but was not limited to the following: -Review 5 rights 3 times -Check Medication Administration Record (MAR) for order -Check the label against the order on the MAR Review of the facility's policy titled Physician Services, dated as revised 11/14/22, indicated but was not limited to the following: -MD orders will be followed by staff as appropriate until the order has been discontinued or changed. Resident #14 was admitted to the facility in November 2023 with diagnoses which included seizure disorder, joint replacement of the right shoulder, Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow), and anxiety. On 9/18/24 at 10:18 A.M., the surveyor observed Nurse #1 prepare and administer Resident #14's scheduled 9:00 A.M. medications including: -Buspar 5 milligrams (mg) one tablet -Neurontin 600 mg two tablets -Tylenol Extra Strength 500 mg one tablet Review of Resident #14's active Physician's Orders indicated the following: -Buspar 10 mg once a day, dated 5/15/24 -Neurontin 600 mg one tab three times a day, dated 1/25/24 -Tylenol Extra Strength 500 mg give two tabs = 1000 mg three times a day, dated 1/25/24 -Anoro Ellipta 62.5-25 micrograms (mcg) one inhalation once a day, dated 1/25/24 -Fluticasone Propionate 50 mcg one spray in nostrils once a day, dated 1/25/24 -Ipratropium Bromide 0.02% inhalation three times a day, dated 2/15/24 -Lidocaine adhesive patch 4% apply two patches to right shoulder once a day, dated 1/25/24 Nurse #1 administered the incorrect dose of Buspar, Neurontin and Tylenol. Nurse #1 failed to administer Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide, and Lidocaine patches. During an interview on 9/18/24 at 2:14 P.M., Nurse #1 said Resident #14 has a nighttime dose of Buspar 5 mg and she administered the nighttime dose by accident. She said she administered the incorrect dose of Neurontin. Nurse #1 said when preparing the Tylenol, she dropped one tablet on the medication cart and disposed of it and forgot to put another tablet into the medication cup. She said Resident #14 refuses the Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide all the time, so she does not administer it. Nurse #1 said she cannot apply the Lidocaine patches to Resident #14's right shoulder, because the Resident is wearing a brace. During an interview on 9/18/24 at 3:47 P.M., the Assistant Director of Nursing (ADON) said her expectation is for the nurse to administer medications as ordered by the doctor.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure staff properly labeled all medications stored in one of four medication carts reviewed once opened; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of two medication room refrigerators reviewed. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised 2024, indicated but was not limited to the following: -Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. -Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure purity and potency. -Once opened, these will be good to use until the manufacturer's date is reached unless the medication is: a. a multi-dose injectable vial b. an item for which the manufacturer has specified usable life after opening -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. 1. Review of a facility document titled Medications with Shortened Expiration Dates, dated [DATE], indicated but was not limited to the following: -Lantus (insulin glargine, treats diabetes) - Vial: once opened, product expires 28 days after first use or removal from refrigerator, whichever comes first. On [DATE] at 9:14 A.M., the surveyor reviewed the Cityside Unit side 1 medication cart with Nurse #4 and observed the following: -one multidose vial of Lantus (insulin glargine, treats diabetes) stored inside a plastic storage container, not stored in its packaging box, pop top off the vial indicating it had been opened, vial not labeled with the date when opened or the new date of expiration, labeled with a resident's name During an interview on [DATE] at 9:19 A.M., Nurse #4 said she didn't know when the bottle was opened. She said the insulin should have had the date when opened and the discard date to ensure it was not expired. During an interview on [DATE] at 10:15 A.M., the Director of Nursing (DON), Administrator, and Consulting Staff #1 said the Lantus should have been labeled with the date when opened and the new date of expiration. The DON said the Lantus was only good for 28 days once opened and had a short expiration date to stay effective. 2. On [DATE] at 7:55 A.M., the surveyor reviewed the Harborside 1 Unit medication storage room with Nurse #3 and observed one bottle of lorazepam (benzodiazepine/schedule IV-controlled substance, treats anxiety) oral concentrate 2 milligrams (mg)/milliliter (ml) stored inside the packaging box in a clear locked controlled substance box inside the refrigerator. The box was affixed to a shelf; however, the shelf was not affixed to the refrigerator. The surveyor was able to take the shelf out of the refrigerator with the box attached. During an interview on [DATE] at 7:55 A.M., Nurse #3 said the controlled substance box should be permanently affixed and she had asked maintenance five times for it to be fixed but they said they couldn't. During an interview on [DATE] at 10:08 A.M. with the DON, Administrator, and Consulting Staff #1, Consulting Staff #1 said the policy was for the box to be double locked, which it was, but not permanently affixed. She then said the refrigerator was locked to avoid having to permanently affix it because it couldn't be.

Based on observation, interview, and document review, the facility failed to ensure professional standards of care were met for two Residents (#145 and #14), out of a total sample of 31 residents. Specifically, the facility failed: 1. For Resident #145, to administer care (one to one (1:1) assist during intake by mouth (PO)) in accordance to physician's orders; and 2. For Resident #14, to follow the standard of medication preparation and administration and document missed or refused medications that were ordered by the physician. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's 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. Review of the facility's policy titled Physician Services, dated as revised on 11/14/2022, indicated but was not limited to the following: - Therapeutic diets are prescribed and precise as to the specific dietary requirements or limitations - Physician (MD) orders will be followed by staff as appropriate until the order has been discontinued or changed 1. Resident #145 was admitted to the facility in August 2024 with diagnoses including pneumonitis (an inflammation of the lung) due to inhalation of food and vomit, dysphagia (difficulty swallowing), and epilepsy. Review of the active Physician's Orders for Resident #145, dated 9/18/24, indicated but were not limited to the following: - 1:1 assist with all PO intake. Fully upright with all meals. Pt active with speech language pathologist (SLP) for dysphagia eval and treatment. Every shift (8/30/24) During an observation on 9/18/24, the surveyor observed Resident #145 at the following times: - 8:31 A.M., in room sitting on the edge of the bed consuming breakfast consisting of a muffin, scrambled eggs, hot cereal and juice, no staff was present in the room to assist the Resident - 8:33 A.M., Certified Nurse Assistant (CNA) #2 enters the room and encourages the Resident to continue to eat his/her meal, leaving the Resident alone at 8:37 A.M., to continue eating and not providing the ordered 1:1 assist - 8:43 A.M., CNA #2 reenters the room and asks the Resident if they are doing okay and exits the room, leaving the Resident alone at 8:43 A.M., to continue eating their breakfast without the ordered 1:1 assist - 8:49 A.M., the Resident has consumed the majority of their scrambled eggs and is pulling a muffin apart with his/her hands, they remain without the ordered staff present to provide a 1:1 assist - 9:02 A.M., CNA #3 enters the room, asks the Resident if they have finished and then removes the breakfast tray from the room During an interview with observation at 8:51 A.M., the SLP observed the Resident eating breakfast alone in their room, she said there is an order currently in place for 1:1 assist with all intake, but the Resident was being discharged from SLP services today and would only require their food to be cut up small once the discharge paperwork was complete but she had not completed it at that time. During an interview on 9/18/24 at 9:02 A.M., CNA #3 said the Resident used to require 1:1 for meals and intake but she didn't think that was required any longer and was unaware of the physician order in place. During an interview on 9/18/24 at 9:04 A.M., Unit Manager #4 reviewed the active physician's orders for Resident #145 with the surveyor and said the Resident should have been provided the 1:1 assist in accordance with the physician order and was not. She said the expectation is for all staff to follow MD orders as written. Review of the activities of daily living (ADL) and mobility flow sheet for Resident #145 from 9/1/24 through 9/18/24, indicated but was not limited to the following: - 37 of 54 potential opportunities for eating ability were documented - 3 of 37 documented opportunities indicated the Resident required set up or clean up assistance (helper sets/cleans up; resident completes activity) - 34 of 37 documented opportunities indicated the Resident was independent (completes the activity by themselves with no assistance from a helper) Review of the CNA care card, undated, for Resident #145 indicated but was not limited to the following: - Diet: regular chopped thin - Independent with set up - No aspiration precautions Review of the SLP therapy documentation for Resident #145 indicated but was not limited to the following: 8/30/24 Evaluation and plan of treatment: - Current referral reason: Patient (Pt) with diagnosis (dx) of aspiration pneumonia. admitted with soft ground/thin diet. At the time of the evaluation nothing by mouth (NPO) was recommended due to continued aspiration risk, but decision was made to continue ground/thin diet despite continued risk of aspiration. Question safety with PO intake, question least restrictive diet. Aspiration precautions; Pt requires supervision at mealtime 76-90% of the time. Summary of skilled service notes: - 8/30/24: Silent aspiration cannot be ruled out; Pt to continue on soft/thin diet at this time with 1:1 supervision - 9/6/24: Pt able to self-feed liquids, banana and sausage with set up. Pt accepted 100% of morning (A.M.) meal from CNA without signs and symptoms of reflexive aspiration. - 9/11/24: Pt assessed with regular texture all cut up and small portions presented; max cues to alternate liquids and solids, no overt signs of aspiration - 9/17/24: Pt continues to benefit from food being cut up to assist with decreased bite size; exhibits mildly extended mastification (process of chewing food); barriers impacting treatment include moderate cognitive impairment, nursing care required and difficulty learning new information 9/18/24 Discharge Summary: - Set up/cut up all meals; alternate liquids and solids; upright posture during meals; regular textures thin liquids diet During an interview on 9/18/24 at 12:18 P.M., Unit Manager #4 said she contacted the physician for Resident #145 and received orders to discontinue to 1:1 assist with meals today, after the surveyor inquired, and also updated the care plan today to reflect these changes, but dated back to 9/12/24 when the diet order was changed as recommended by the SLP. Review of the care plans for Resident #145 indicated but were not limited to the following: Problem: 9/3/24: Resident requires mechanically altered diet related to dysphagia and difficulties chewing and requires sufficient feeding assistance 9/18/24: Diet upgrade on 9/12/24 and independent eating per SLP and MD approval During an interview on 9/18/24 at 12:25 P.M., Nurse #5 said she received the recommendations from SLP on 9/12/24 and contact the physician for new orders. She said on 9/12/24 she received orders from the physician to change the diet to Regular texture. She said she probably should have addressed the Resident's order for 1:1 assist at that time but did not and that is why the order remained active. She said the order for 1:1 assistance with all PO intake was active at the time the surveyor observed the Resident on 9/18/24 and should have been followed as ordered by the physician and was not. Review of the SLP Physician orders request forms for Resident #145 indicated, but were not limited to the following: 8/30/24: 1:1 assist with PO intake; fully upright with all meals 9/12/24: Discontinue mechanical soft/ground diet; house regular diet - cut up The SLP recommendations did not include the discontinuation of 1:1 assist. During an interview on 9/19/24 at 8:33 A.M., the Director of Nurses (DON) and SLP said the Resident was self-feeding and doing well with their skilled SLP services up to the time of discharge from SLP, which was completed yesterday, 9/18/24. The SLP said she never put in a recommendation to discontinue to 1:1 assistance for the Resident and that is likely the reason the order remained active at the time of the 9/18/24 observation. The DON said the expectation is that staff are following all active MD orders as written until the order is discontinued in accordance with the standard of nursing practice. 49425 2. Review of the facility's policy titled Administration Procedures for All Medications, dated as last revised 2024, indicated but was not limited to the following: -Review 5 rights 3 times -Check Medication Administration Record (MAR) for order -Check the label against the order on the MAR -After administration, return to cart, document administration in the MAR -If resident refuses medication, document refusal on MAR. -Notification of Physician/Prescriber for persistent refusals Resident #14 was admitted to the facility in November 2023 with diagnoses which included seizure disorder, joint replacement of the right shoulder, Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow) and anxiety. On 9/18/24 at 10:18 A.M., the surveyor observed Nurse #1 prepare and administer Resident #14's scheduled 9:00 A.M. medications including: -Buspar 5 milligrams (mg) (for anxiety) one tablet -Neurontin 600 mg (for seizures or nerve pain) two tablets -Tylenol Extra Strength 500 mg (for mild/moderate pain) one tablet Review of Resident #14's active Physician's Orders indicated the following: -Buspar 10 mg once a day, dated 5/15/24 -Neurontin 600 mg one tab three times a day, dated 1/25/24 -Tylenol Extra Strength 500 mg give two tabs = 1000 mg three times a day, dated 1/25/24 -Anoro Ellipta 62.5-25 micrograms (mcg) (inhaler for lung conditions) one inhalation once a day, dated 1/25/24 -Fluticasone Propionate 50 mcg (inhaler for lung conditions) one spray in nostrils once a day, dated 1/25/24 -Ipratropium Bromide 0.02% (aerosol for lung conditions), inhalation three times a day, dated 2/15/24 -Lidocaine adhesive patch 4% (local anesthetic for pain management), apply two patches to right shoulder once a day, dated 1/25/24 The surveyor did not observe Nurse #1 follow the 5 Rights and 3 Checks when administering the incorrect doses of Buspar, Neurontin and Tylenol Extra Strength and failed to document that Resident #14 was not administered the Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide, and Lidocaine patches as ordered by the physician. Review of the Medication Administration Record (MAR) indicated the Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide, and Lidocaine patches to the right shoulder were signed off as administered on 9/18/24 at 10:18 A.M. During an interview on 9/18/24 at 2:14 P.M., Nurse #1 said Resident #14 has a nighttime dose of Buspar 5 mg, and she administered the nighttime dose by accident. She also said she administered the incorrect dose of Neurontin. Nurse #1 said when preparing the Tylenol, she dropped one tablet on the medication cart and disposed of it and forgot to put another tablet into the medication cup. She said Resident #14 refuses the Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide all the time, so she does not administer it. Nurse #1 said she cannot apply the Lidocaine patches to Resident #14's right shoulder, because the Resident is wearing a brace. She said she signed all of the missed medications off as administered on the MAR by mistake. During an interview on 9/18/24 at 3:47 P.M., the Assistant Director of Nursing (ADON) said her expectation is for the nurse to administer medications as ordered by the doctor. She said the nurse should not have documented any medication as administered if it was not. During an interview on 9/19/24 at 12:52 P.M., the Director of Nursing (DON) said her expectation is for medications to be administered per the Physician's orders. She said the Physician is to be notified of incorrect or omitted medications, and a medication error form must be completed. DON said the medications omitted should have been documented as not given in the medical record, and the nurse should have documented the reason for not administering the medications in a nursing note. Refer to 759

Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#114), out of a total sample of three residents observed on a medication pass, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another). Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised August 2017, indicated but was not limited to the following: When to wash hands (at a minimum) -Before and after direct patient/resident contact -After completing tasks at one patient/resident area before moving to another station -Before procedures, such as administering medications -After contact with items/surfaces in patient/resident areas When to use the alcohol hand sanitizer -After contact with resident intact skin -Before entering the resident rooms -Before exiting the resident rooms Review of the facility's policy titled Administration Procedures for all Medications, dated as revised 2024, indicated but was not limited to the following: -Cleanse hands using antimicrobial soap and water, or facility approved hand sanitizer before beginning a medication pass, before handling medication, and before contact with the resident. -When finished with each resident, wash hands with antimicrobial soap and water or use facility approved hand sanitizer. Review of the facility's policy titled Oral Medication Administration, dated as revised 2024, indicated but was limited to the following: -Wash hands when beginning a medication pass, or when contact with resident is expected or has occurred. -Pour or push the correct number of tablets or capsules into the cup, taking care to avoid touching the tablet or capsule, unless wearing gloves -When finished with each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer. Review of the facility's policy titled Injectable Medication Administration, dated as revised 2024, indicated but was not limited to the following: -Equipment required: Examination gloves Review of Centers for Disease Control and Prevention (CDC) guidance titled Infection Control in Healthcare: An Overview, dated 2/7/24, indicated but not limited to the following: Common reservoirs in and on the human body: Skin -Many germs live and grow on healthy skin and normally do not cause harm. -Your skin interacts with the environment daily, especially when you touch things with your hands. -Pathways for germs to spread from skin include: -Touch, especially with your hands. Review of Centers for Disease Control and Prevention titled Infection Control Basics, dated 4/3/24, indicated but not limited to the following: Transmission can happen through activities such as: -Physical contact, like when a healthcare provider touches medical equipment that has germs on it and then touches a patient before cleaning their hands. Resident #114 was admitted to the facility in July 2022 with diagnoses including Type II Diabetes. On 9/18/24 at 9:20 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #114 which included the following: -Nurse #1 had a medication cup with four tablets inside -Nurse #1 spilled two white, round tablets onto the medication cart -Nurse #1 picked up the tablets from the medication cart and placed them back into the cup with her bare hands -Nurse #1 prepared insulin injections at the medication cart as ordered and entered Resident #114 room carrying the medication cup of tablets and capsules and two insulin syringes -Nurse #1 did not perform hand hygiene prior to entering the room -Nurse #1 administered all eleven tablets and four capsules to Resident #114 with a cup of water -Nurse #1 cleansed Resident #114's left upper arm with an alcohol swab and injected one syringe of insulin -Nurse #1 cleansed Resident #114's left upper arm, with an alcohol swab and injected the other syringe of insulin. -Nurse #1 did not don (put on) gloves prior to administering the insulin injections -Nurse #1 exited Resident #114's room, disposed of the used needles in the sharps container located on the medication cart, and did not perform hand hygiene -Nurse #1 then began preparing another resident's medication At no time during the observation, did the surveyor observe Nurse #1 perform any type of hand hygiene. During an interview on 9/18/24 at 10:30 A.M., Nurse #1 said she should have discarded the medication she touched with her bare hands and not given it to Resident #114. She said that she usually wears gloves to give an injection, but she forgot to bring them into the room. Nurse #1 said she forgot to use the hand sanitizer before and after giving medications. During an interview on 9/18/24 at 3:35 P.M., the Assistant Director of Nurses (ADON) said her expectation is when medications are contaminated, they need to be wasted and not administered to the resident. She said hand hygiene should be done before and after all medication administrations. The ADON said gloves must be worn for all injections due to the increased risk of coming in contact with bodily fluids. During an interview on 9/19/24 at 12:52 P.M., the Director of Nursing (DON) said her expectation is for infection control guidelines to be maintained at all times, as a standard of practice. She said medications are never touched with bare hands, and if they are they must be disposed of and not given to the resident. She said when giving injections, gloves are worn to decrease the risk of cross contamination. She said hand hygiene should have been performed prior to entering and when exiting Resident #114's room, and after disposal of the dirty needles.

Based on resident and staff interviews, observation, and meal test trays on two of three units, the facility failed to prepare and serve meals in a manner conserving flavor, were palatable, and served at safe and appetizing temperatures. Findings include: Review of Resident Council Meeting Minutes, dated 6/26/24, indicated several residents were concerned about food temperatures and receiving cold food. During a Resident Council Meeting held on 9/18/24 at 1:00 P.M. by the survey team, 14 out of 14 residents present at the meeting said there was a concern about cold food temperatures across all mealtimes. On 9/19/24 at 11:30 A.M., the surveyor requested a lunch test tray to the Harborside Two Unit. The food truck left the kitchen at 11:53 A.M. and arrived at 11:55 A.M. on the unit. The test tray was conducted with the Dietitian observing at 12:06 P.M. with the following results in degrees Fahrenheit (F): - Sweet and Sour Chicken: 138.8 F - Mixed Vegetable (Carrots, Broccoli, Cauliflower): 108.7 F: soft, lacking flavor, cold to taste - Rice: 116.5 F: bland tasting, cold to taste - Strawberries: 50.8 F: warm to taste/touch, watery tasting - Milk: 54.2 F: warm to taste/touch Of note, the test tray was delivered to the unit on a pushcart by the dietary aide. An additional resident tray was also observed on the pushcart. All additional resident trays were delivered to the unit in a closed truck. On 9/23/24 at 8:00 A.M., the surveyor requested a breakfast tray to the Cityside Unit. The food truck left the kitchen at 8:20 A.M. and arrived at 8:26 A.M. on the unit. The test tray was conducted with the Dietitian observing at 8:34 A.M. with the following results: - Hard Boiled Egg: 128.0 F: warm to touch/peel, yellow cooked yolk - Oatmeal: 134.1 F: cool temperature, watery, lacking flavor - Muffin: 110.0 F: warm to touch - Milk: 49.1 F - Coffee: 150.6 F During an interview on 9/23/24 at 8:38 A.M., the Dietitian said the meal temperatures observed were not within appropriate ranges: hot items on resident meals should be 140 F when arriving to the resident and the milk temperature was too warm. The Dietitian said she would not expect trays to be delivered on a pushcart to the unit during meal times and that meals should remain in the delivery truck with the door closed to maintain proper temperatures until the tray is ready to be delivered to the resident.

Based on observation, interview, and document review, the facility failed to ensure one Resident (#303) was informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 31 residents. Findings include: Review of the facility's policy titled Baseline Care Plan, dated as revised 8/15/23, indicated but was not limited to: - a baseline care plan is developed within 48 hours of admission to the facility Process: - interview resident, obtain physician orders, complete admission nursing assessment and begin interdisciplinary (IDT) assessment, review transfer information, develop baseline care plan with IDT, continue to gather information - the facility will provide the resident with a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, summary of resident's medications and dietary instructions, any services and treatments to be administered by the facility Resident #303 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease (illness affecting the blood vessels of the brain) and diabetes mellitus. Review of the Admission assessment for Resident #303, dated as completed on 9/16/24, indicated but was not limited to the following: - Resident is cooperative with clear speech and adequate hearing and vision - Resident is alert, verbal and comprehensible (easy to understand), and oriented to person, place and time During an interview on 9/17/24 at 8:50 A.M., Resident #303 said he/she was admitted to the facility a couple days prior and that he/she did not know what the plan was for their short-term stay, but they were supposed to have a meeting to discuss the plan and his/her goals and they were waiting for that to occur. The Resident said the staff were not answering any of their questions to let them know what the plan was for care or their individual goals for discharge and they were frustrated. The Resident said they had not yet had a meeting with the IDT or been offered a summary of their care plan or initial goals while at the facility. Review of the medical record for Resident #303 failed to indicate a baseline care plan summary had been completed or that the Resident had been offered or provided a copy of their medications and care activities to be performed while at the facility. During an interview on 9/18/24 at 8:22 A.M., Resident #303 said he/she was aware of their medication changes, but they had not been explained to him/her and he/she had still not had a meeting or been offered any information on their care and what services they would receive while at the facility for their short-term stay. The Resident said he/she was concerned that the facility was not collaborating with him/her regarding their personal goals for their stay and what needed to be accomplished for him/her to return to the community as soon as possible. Resident #303 said he/she was going to self-advocate and request the information today since he/she has their mind and has not been offered any information yet. During an interview on 9/18/24 at 9:17 A.M., the Case Manager said the process for new admission residents and baseline care plans is for the IDT to meet with each resident within two days of admission. She said the meeting includes the resident and the IDT and is collaborative to review the resident's individual goals and plans and create a tentative plan for them to reach those goals prior to the comprehensive plan being made. She said after the meeting the resident is asked to sign a copy of the baseline plan of care summary and is offered and provided a copy to ensure they are aware of the plan and a copy is kept in the medical record. During an interview on 9/18/24 at 12:28 P.M., Unit Manager (UM) #4 reviewed Resident #303's medical record with the surveyor and said the Resident did not have a signed baseline plan of care summary in their record and she was unsure of when the meeting took place or where the summary was but she would look for it and provide it to the surveyor. During an observation with interview on 9/18/24 at 12:42 P.M., the Surveyor observed UM #4 bringing a care plan summary form to Resident #303's room and followed the UM to the room. The Resident was in the room with Social Worker (SW) #2 when the UM and surveyor arrived. The form was handed to Resident #303 and SW #2 informed the Resident that he/she forgot to sign the form from the meeting held on 9/16/24. The Resident insisted he/she did not have a meeting on 9/16/24 and the meeting was being held now. The Resident was becoming increasingly frustrated with the insistence on the part of SW #2 that he/she had forgotten they had a meeting and said, You're trying to bamboozle me and You're trying to make me think I'm crazy and I don't know stuff but I know that we did not have a meeting on Monday. Upon the surveyor intervening, SW #2 said the Resident is alert and oriented and she did not attend the meeting on Monday (9/16/24) but that is the process and she is sure he/she had one. The Resident said there was no meeting and he/she had met with the case manager individually and then on separate occasions and different days some other people but no one had offered him/her a copy of the summary or asked them for their individual goals. The Resident said he/she would sign the paper and asked what the date was, the UM said the facility had already dated the form for Monday and the Resident said again that they did not meet and questioned why they would back date the paper and reminded the staff no one offered him/her the summary on that day and a meeting was not held. During an interview on 9/18/24 at 12:46 P.M., SW #2 provided the surveyor with a copy of the baseline care plan summary dated 9/16/24 signed by herself and the Resident. She said she pre-signed the paper when she was completing her piece and when the team came to have the meeting with the Resident they were not available and she was pulled away and did not attend the meeting and couldn't speak to who was at the meeting or when it occurred since she was not there. Review of the baseline care plan summary dated as completed 9/16/24 indicated the Resident had the information reviewed with them, but the form was unsigned until the Resident signed it, as observed by the surveyor on 9/18/24. During an interview on 9/18/24 at 12:52 P.M., Resident #304, who is Resident #303's roommate and alert and oriented, said he/she was in the room most of the day on 9/16/24 and had met with the IDT. The Roommate said Resident #303 was correct when he/she said he/she was not seen by the IDT and did not have a baseline plan of care summary signed on Monday 9/16/24 because Resident #303 was out of the facility early in the morning and did not return until later in the day. The Roommate said the IDT team returned to see Resident #303, but he/she was unavailable until late afternoon. During an interview on 9/18/24 at 1:02 P.M., the Director of Nurses (DON) and Consultant #1 were made aware of the concerns and surveyor's observations regarding Resident #303. The DON said the expectation is that the IDT hold a meeting with the resident and the meetings are held within 48 hours. She said the Resident was admitted on a Sunday and therefore their meeting would have had to be completed by the end of day Tuesday. She said the staff do complete sections of the form prior to meeting with the residents but in this instance the dates on the form should have been corrected to indicate the date the Resident participated in the care plan and was offered the summary. Consultant #1 said the staff should have adjusted the dates on the form to reflect the accurate date of the meeting and information sharing and allowed the Resident to sign and date the form for today (9/18/24) and the process for completing the baseline care plan and offering the Resident a copy was not followed within the 48-hour time frame or to expectation. Both the DON and the Consultant said the baseline care plan process did not work as it should have for this Resident. During an interview on 9/18/24 at 1:52 P.M., UM #4 said she should not have dated the baseline care plan summary for 9/16/24 and should have dated it for 9/18/24 since that was the first time any of the information had been discussed with the Resident and the Resident was offered a copy. She said she was not present at a meeting for the Resident on 9/16/24 and she cannot say whether one actually took place. She said the form did not reflect the correct date or information as it should and the Resident should have been allowed to date it correctly when he/she signed it. During an interview on 9/18/24 at 2:02 P.M., Nurse #5 said on 9/16/24 Resident #303 left the facility at approximately 8:00 A.M., for an appointment and did not return to the facility until about 2:30 P.M., she said she did see a few IDT members go to the Resident's room after he/she returned but no meeting was held for the Resident on that date because the Resident was not available in the facility and the form in the record was inaccurate based on the date of completion. She said the team did meet and discuss the Resident on 9/16/24 but the Resident was not involved and the summary was not offered to him/her. During an interview on 9/19/24 at 7:45 A.M., the Administrator said she was made aware of the situation that occurred with Resident #303 and their baseline care plan. She said since the information was inaccurate, she had staff meet with the Resident again on 9/18/24 and offer to correct the information and the form, which the Resident was appreciative of, and provided the Resident with a new copy of their baseline care plan summary dated as complete on 9/18/24. She said this meeting and the summary was not provided to the Resident within 48 hours as it should have been per the policy and regulation; the process was not followed as expected. Review of the Baseline plan of care for Resident #303, dated as completed 9/18/24, indicated the Residents preferences for sleep and individual goals and was signed and dated by the Resident, UM #4, Case manager, Director of Rehabilitation, MDS Nurse and SW #2 on 9/18/24. During a follow up interview on 9/19/24 at 9:28 A.M., Resident #303 said he/she feels good about the facility taking his/her input and correcting the baseline care plan to be collaborative and include his/her personal goals and preferences and was happy that the facility allowed him/her to have the form dated appropriately.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who complained of abdominal pain and experienced multiple episodes of diarrhea for several days which interfered with his/her ability to participate in rehabilitation therapy, the Facility failed to ensure nursing notified his/her Physician in a timely manner of his/her change in condition, in an effort to obtain orders to meet his/her care and treatment needs. Findings Include: Review of the Facility Policy titled, Condition: Significant Change, dated as last revised 2/16/16, indicated that professional staff will promptly communicate with the physician, resident, and family regarding changes in condition. The Policy further indicated that the notification including date, time, and by whom, shall be documented in the clinical record by appropriate personnel. Resident #1 was admitted to the Facility in December 2022, diagnoses included sepsis (an infection in the blood), pneumonia, chronic obstructive pulmonary disease, respiratory failure, cerebral vascular accident (interruption in blood flow in the brain), and pancreatitis (inflammation of the pancreas). During an interview on 9/12/23 at 11:45 A.M., Family Member #1 said Resident #1 began complaining of abdominal cramping and persistent diarrhea on 2/10/23, that staff did not seem to care and only gave him/her Imodium (medication to treat diarrhea) as an intervention. Family Member #1 said it was very difficult communicating with nursing staff and said that it felt like none of the nursing staff believed that Resident #1 was ill. Review of Resident #1's Physical Therapy (PT) Progress Note, dated 2/09/23, indicated he/she was unable to do stairs or walk secondary to his/her stomach had been hurting. The PT Note indicated nursing was aware. Review of Resident #1's Occupational Therapy (OT) Progress Note, dated 2/09/23, indicated his/her belly hurt and that he/she experienced loose stools, had been incontinent. The Note indicated that PT had reported that nursing staff had been made aware of his/her not feeling well. Review of Resident #1's medical record indicated there was no documentation in his/her nursing progress notes related to his/her complaints of his/her stomach or belly hurting, or that is was reported to his/her physician. Review of Resident #1's Nurse Progress Note, dated 2/13/23, indicated he/she reported to the nurse he/she was having diarrhea. Review of Resident #1's PT Note, dated 2/13/23, indicated he/she declined therapy, reported being sick with loose stools and nursing tested him/her for Covid-19. Review of Resident #1's medical record indicated there was no documentation in his/her nursing progress notes related to his/her reports of diarrhea or of the physician being notified. Review of Resident #1's OT Note, dated 2/14/23 indicated he/she refused therapy, stated that he/she has had diarrhea all day and his/her stomach hurt. Review of Resident #1's PT Note, dated 2/15/23, indicated he/she refused therapy after multiple attempts, he/she complained of not feeling well, and having loose stools. The Note indicated that PT documented that it was discussed with nursing staff. Review of Resident #1's medical record indicated there was no documentation in his/her nursing progress notes related to his/her refusal to participate in rehabilitation, that he/she had continued to report bouts of diarrhea, that his/her stomach hurt or that his/her physician was notified. Review of Resident #1's OT Note, dated 2/15/23, indicated he/she was not feeling well and having frequent episodes of loose stool. Review of Resident #1's PT Note, dated 2/16/23, indicated he/she was still not feeling well and unsure if he/she would be able to return home as planned. The Note indicated PT notified Resident #1's Nurse Manager. Review of Resident #1's OT Note, dated 2/16/23, indicated he/she had loose stools for a few days and nursing was aware. Review of Resident #1's medical record indicated there was no documentation in his/her nursing progress notes related to his/her complaints of not feeling well, concerns he/she would not be able to be discharged home as planned, that his/she continued to experience loose stools, or that his/her physician had been notified. Review of Resident #1's PT Note, dated 2/17/23, indicated he/she was presenting with significant weakness, poor balance, and was unable to come to a full stand. The PT Note indicated that nursing had been notified of his/her change in functional ability. Review of Resident #1's Physician's Order, dated 2/17/23, indicated to obtain a stool sample for C-diff (Clostridium Difficile, a bacterium that causes diarrhea) and to obtain blood laboratory work. Review of Resident #1's OT Note, dated 2/18/23, indicated he/she was feeling weak due to having diarrhea for several days. Review of Resident #1's Nursing Progress Note, dated 2/19/23, indicated he/she had abnormal laboratory results (received that day) and to transfer him/her to the Hospital Emergency Department for evaluation. The Note indicated Resident #1 was admitted with severe Clostridium Difficile Colitis (C-Diff, inflammation of the colon caused by bacteria), an acute kidney injury (when the kidneys suddenly can not filter waste from the blood), and leukocytosis (high white blood cell count). During an interview on 9/14/23 at 1:10 P.M., Occupational Therapist (OT) #1 said she remembered working with Resident #1, and he/she had issues with his/her bowels and diarrhea. OT #1 said she had to assist him/her with incontinent care a few times and reported the diarrhea to the nurse (exact name unknown). During an interview on 9/14/23 at 12:28 P.M., Certified Nurse Aide (CNA) #1 said Resident #1 had multiple episodes of diarrhea and said that she provided incontinent care for him/her multiple times. CNA #1 said she had reported to the nurse. CNA #1 said she does not remember the nurse's name and said she thought it may have been an agency nurse. During an interview on 9/13/23 at 2:23 P.M., CNA #2 said Resident #1 had multiple loose stools and she had assisted him/her with incontinence care. CNA #2 said she remembered telling Resident #1's nurse (exact name unknown) about his/her diarrhea. During an interview on 9/19/23 at 9:35 A.M., Nurse #1 said that on 2/12/23 into 2/13/23, during the 11:00 P.M.-7:00 A.M., shift the CNA reported to her that Resident #1 had smelly diarrhea and she tested him/her for Covid-19. Nurse #1 said she did not notify his/her physician and said she let the oncoming nurse know so they could obtain an order for a stool for C-diff. During an interview on 9/13/23 at 2:50 P.M., the Unit Manager said she was unaware that Resident #1 was experiencing any issues with his/her bowels and said had she known about his/her abdominal pain and complaints of diarrhea, she would have ensured that the physician was notified. During an interview on 9/20/23 at 1:12 P.M., the Nurse Practitioner (NP) said he had last seen Resident #1 on 2/03/23 and there were no concerns of diarrhea or abdominal pain documented at that time. The NP said he was unaware of Resident #1's change in condition until 2/19/23, when he/she was sent out to the Hospital. The NP said the expectation is for the Nursing Staff to inform him (or alternate Provider) of changes in condition of any resident in a timely manner. During an interview on 9/21/23 at 10:56 A.M., the Director of Nurses (DON) said she was unaware that Resident #1 was not feeling well and said nothing in his/her Nursing Progress Notes led her to believe she had been experiencing a change in condition. The DON said it is expected that any significant changes in a residents condition must be communicated to their providers in a timely manner and be documented in their medical record.

Based on observations, record review, and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#122), out of a total sample of 31 residents. Findings include: Resident #122 was admitted to the facility in April 2022 with diagnoses the included but were not limited to chronic obstructive pulmonary disease, chronic respiratory failure, unspecified severe protein calorie malnutrition, adult failure to thrive, depression, and other abnormalities of gait and mobility. Review of Resident #122's Minimum Data Set assessment, with an Assessment Reference Date of 5/12/23, indicated the Resident scored 14 out of 15 on the Brief Interview for Mental Status exam, which indicates intact cognition, requires extensive assistance from two staff for bed mobility, hygiene, and eats independently with set up. Further, the MDS indicated that Resident #122 did not have functional limitation of range of motion in his/her upper extremity. On 6/14/23 at 8:05 A.M., the surveyor observed Resident #122 in bed. His/her right hand was holding a fork and his/her third, fourth and fifth fingers were folded in toward his/her palm and his/her fifth finger was pointed out. Resident #122's fingernails were long and bent into the palm of his/her hand. During an interview and observation on 6/14/23 at 9:21 A.M., Nurse #1 accompanied the surveyor to Resident #122's room. Nurse #1 asked Resident #122 to open his/her right hand and while trying, Resident #122 grimaced and said, Ouch, it hurts. Resident #122 was unable to extend (straighten) his/her third or fourth finger, which were tucked under the fifth finger which was pointed out. Resident #122 said it has been that way since he/she was sick but was unable to say how long that was. Nurse #1 said she was unsure if the nursing staff used to put something in the Resident's hand to straighten his/her fingers and was unsure how long his/her fingers had been bent like this. During an interview on 6/14/23 at 9:48 A.M., Certified Nursing Assistant (CNA) #2 said she has worked with the Resident many times since he/she was admitted . CNA #2 said Resident #122 complains of pain when she tries to open the Resident's right hand to wash it. CNA #2 said Resident #122's fingers do not extend and cannot fully straighten. CNA #2 said she did not know how long Resident #122's fingers were held tight and not able to extend. On 6/14/23 at 9:50 A.M., the surveyor observed Resident #122 with CNA #2. Resident #122 said he/she could not open his/her fingers. Review of the Occupational Therapy Evaluation and Treatment document, dated 4/8/22, indicated the following: * Musculoskeletal System Assessment, RUE (right upper extremity) ROM (range of motion) = WFL (Within functional Limits); tremors; LUE ROM = Within functional limits (limited by tremors) * Contracture Functional limitations present due to contracture = No Review of Resident #122's medical diagnoses failed to indicate a neurological condition that would cause a contracture. Further review of Resident #122's medical record indicated the following: * Admission/re-Admission Nursing Assessment, dated 4/2022, indicated Resident's Range of Motion in Upper Extremities: Left arm-full ROM, Right Arm-Full ROM, Does Resident have any contractures? No * Physician's orders failed to indicate any treatment or monitoring of Resident #122's hand contracture. *Monthly Nursing Summary documents, dated May, June, July, August, September, October, November, December 2022, indicated contractures/deformities were not checked as being present. *Monthly Nursing Summary documents dated January, February, March, April, May 2023, indicated contractures/deformities were not checked as being present. During a phone interview on 6/14/23 at 10:20 A.M., the Director of Rehabilitation (DOR) said long term care residents are screened by rehabilitation when a resident is on the CASPER (a quality measure report based on submitted MDSs,) as having a decline, by staff referral for a change in function, physician orders, discussion in morning meeting. The DOR said if a screen was completed for a resident, it would be in the medical record on paper. The DOR said he did not recall Resident #122. The DOR said if residents are admitted without a contracture, it would be expected that rehabilitation be consulted for a screen even if the goal of care is for comfort or the resident is on hospice because the risks associated with a contracture are skin breakdown, further discomfort, pain and loss of function. During an interview on 6/14/23 at 11:55 A.M., the Director of Nurses (DON) said the Resident did not have documentation of a contracture of his/her hand on admission and that Resident #122 has a new contracture and she was unable to determine how long the contracture was present. During an interview with the DON and Resident #122's Physician on 6/14/23 at 1:03 P.M., the DON said Resident #122 came off hospice in February and is on palliative care services. The Physician said she had seen Resident #122 use his/her right hand to eat. The Physician said Resident #122 has presented more debilitated at 78 pounds and the Residents' goal to stay in bed and be comfortable and free of pain. The Physician said the Resident's muscles are contracting and his/her joints are weaker which could contribute to contractures and acknowledged the right-hand contracture was not identified. Occupational Therapy (OT) screened Resident #122 after the DON and surveyor spoke. Review of the Rehabilitation Screening Form, dated 6/14/23 indicated Pt (patient) referred by nursing for worsening hand contractures. Pt seen by OT who observed contractures of BUE (bilateral upper extremities) Right greater than the Left. Pt reports having pain attempting PROM (passive range of motion) of right hand. Pt also reports he/she completes self-feeding with right hand and has some difficulty. During an interview on 6/14/23 at 12:30 P.M., the OT said he just screened Resident #122 and said he/she had bilateral hand contractures and complained of having pain today. The OT said he could not determine how long the contractures have been present. The OT reviewed the previous OT evaluation from 4/8/22 and said if contractures had been present at the time of that evaluation, it would have been documented. During an observation and interview on 6/14/23 at 10:45 A.M., the DON accompanied the surveyor to Resident #122's room. The DON observed Resident #122's right hand and said it was contracted. The DON attempted to passively straighten the fingers and Resident #122 winced with pain. The DON said the goal for residents would be to prevent the development of a contracture and prevent a decline in a contracture.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#113) was free from restraints, out of a total sample of 31 residents. Specifically, for Resident #113 the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint. Findings include: Review of the facility's policy titled 'Restraints', dated as revised 10/20/21, indicated the following: Purpose: Therapeutic use of a device used as a restraint may be used when all other interventions or alternatives to a restraint are not effective. Procedure: 1. If a restraint is used a licensed therapist and/or a nurse will assess the resident for appropriate interventions and a plan of care will be developed. Documentation within the medical record will include verification that: - The resident has medical symptoms for which the restraints have been determined to achieve or maintain the highest level of mental, physical, and psychosocial well-being. Resident #113 was admitted to the facility in November 2021 with diagnoses including malignant neoplasm part of bronchus or lung and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/5/23, indicated that Resident #113 was assessed by staff to have severe cognitive impairment and is rarely/never understood. The MDS further indicated Resident #113 is totally dependent on staff for all Activities of Daily Living (ADLs). The MDS failed to indicate the use of restraints. On 6/12/23 at 1:28 P.M., the surveyor observed Resident #113 lying in bed with pillows tucked under the fitted sheet on each side of the bed, potentially preventing him/her from getting out of bed. The bed was in the low position and a floor mat was on the floor beside the bed. On 6/13/23 at 2:35 P.M., the surveyor observed Resident #113 lying in bed with a pillow tucked under the fitted sheet on his/her right side of the bed potentially preventing him/her from getting out of bed. Review of the care plan failed to indicate a plan of care for the use of a restraint or the use of pillows under the fitted sheet on both sides of the bed. Review of the Physician's Orders, dated June 2023, failed to indicate an order for the use of a restraint. During an interview on 6/13/23 at 12:57 P.M., Certified Nursing Assistant (CNA) #1 said that she places the pillows under the fitted sheet to prevent the Resident from falling out of bed, she further said that if she doesn't use the pillows the Resident will swing his/her legs over the side of the bed trying to get out. During an interview on 6/13/23 at 2:35 P.M., Nurse #1 said they use the pillows under the fitted sheet to prevent the Resident from falling out of the bed. She further said without a restraint assessment the pillows are considered a restraint as the Resident has a perimeter mattress. During an interview on 6/13/23 at 1:28 P.M., the Director of Nursing said that the use of pillows should be for positioning and that they should not be under the fitted sheet. She added that if pillows are placed under the fitted sheet, then a care plan would be in place.

Based on observations, policy review, and interview, the facility failed to provide a dignified dining experience for one Resident (#113), out of a total sample of 31 residents. Specifically, staff stood over the Resident while feeding him/her meals, rather than seated at eye level. Findings include: Review of the facility's policy titled Resident Rights, dated as revised 11/28/21, indicated: *The Resident has the right to be treated with respect and dignity. Resident #113 was admitted to the facility in November 2021 with diagnoses including malignant neoplasm part of bronchus or lung and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/5/23, indicated that Resident #113 was assessed by staff to have severe cognitive impairment and is rarely/never understood. The MDS further indicated Resident #113 was totally dependent on staff for all Activities of Daily Living (ADLs). On 6/12/23 at 8:22 A.M., the surveyor observed a Certified Nursing Assistant (CNA) feeding Resident #113. The CNA was standing over Resident #113 while feeding him/her, the Resident's bed was not raised, and the CNA was not at eye level with Resident #113. On 6/13/23 at 9:04 A.M., the surveyor observed CNA #1 feeding Resident #113. CNA #1 was standing over Resident #113 while feeding him/her, the Resident's bed was not raised, and the CNA was not at eye level with Resident #113. On 6/13/23 at 12:28 P.M., the surveyor observed Nurse #1 feeding Resident #113. Nurse #1 was standing over Resident #113 while feeding him/her, the Resident's bed was not raised, and the nurse was not at eye level with Resident #113. During an interview on 6/13/23 at 1:00 P.M., CNA #1 said she is supposed to be seated at eye level while feeding residents. During an interview on 6/13/23 at 1:00 P.M., Nurse #1 said all staff are supposed to be seated at eye level with residents during meals. Nurse #1 said she should have been sitting down while assisting Resident #113 with his/her meals. During an interview on 6/13/23 at 1:26 P.M., the Director of Nursing said staff should be seated at eye level while assisting residents with meals.

Based on record review, policy review, and interview, the facility failed to report to the Department of Public Health's (DPH's) Health Care Facility Reporting System (HCFRS) a possible misappropriation of a discharged resident's property. Specifically, a family member completed a facility Complaint/Concern/Grievance Report form, which alleged 100 dollars was taken from a drawer. Findings include: Review of the facility's policy titled Abuse Prohibition, with a revision date: 10/11/2022, indicated the following: Definition: Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Examples include taking the resident's money or clothing or using a resident's telephone. Further, the policy indicated: Reporting/Responses; All alleged violations of incidents included within the definition of abuses, mistreatment, neglect, involuntary seclusion, or misappropriation of resident property shall be reported to the Department of Public Health, Division of Health Care Quality upon receipt of the facility's report of basic findings. During a review of the facility's Grievance Binder on 6/13/23 at 3:26 P.M., the surveyor reviewed a grievance, dated 6/20/22. The form was completed by a discharged resident's family member. The family report: On January 26 an envelope with $100.00 (10, $10 bills) was put in my top drawer. On January 29 the envelope was no longer there. The grievance further indicated that the family member wrote Investigate who took the money and return it. * The facility's documented conclusion was: Facility searched, and money was unable to be located. Resident issued a lock box/key. No further documentation was attached to the document. Review of DPH's HCFRS failed to indicate the facility reported the potential misappropriation of money. During an interview on 6/13/23 at 5:18 P.M., the facility's Administrator reviewed the grievance with the surveyor and said it did allege that someone took the resident's money. The Administrator said that this should have been reported to DPH's HCFRS and that she intended to file a late report.

Based on record review and interviews, the facility failed to ensure the nursing staff followed the standard recommendations and the Facility protocol for mechanical lift transfers for 1 resident (#23) out of a total sample of 24 residents; and, based on observations and interviews with staff, the facility failed to ensure that the environment was free of accident hazards, by failing to secure windows from opening beyond 4 inches, and failing to consistently maintain and secure storage closets that included the clean and dirty utility closets, and electrical closets. Findings include: 1. For Resident #23 the facility failed to ensure the staff followed the standard recommendations and the Facility protocol for mechanical lift transfers. The Certified Nursing Assistant (CNA) transferred Resident #23 without another staff member present for the entire process of transferring the Resident from bed to chair. Review of the closed medical record indicated Resident #23 had been admitted to the facility in 3/2015 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 4/5/15, indicated that Resident #23 had short and long term memory loss and was dependent for transfers. The plan of care for activities of daily living, dated 4/9/15, included 2 assist with mechanical lift for transfers to wheelchair. The standard of mechanical lifts according to the the Department of of Health and Human Services, Centers for Disease and Prevention and National Institute for Occupational Safety and Health, as well as the facility's policy and procedure recommended 2 staff assist for all lift preparation and transfers. Record review and review of the incident/accident report dated 6/7/15, indicated the CNA caring for the Resident on 6/7/15 was aware and competent in her understanding for 2 staff to assist for lift preparation and transfers. The CNA reported in her statement, dated 6/7/15, that no one had been available to help her transfer the Resident (as everyone was busy), so she tried to transfer the resident from the bed to the wheelchair via a mechanical lift alone. The CNA stated when she went to put the Resident into the wheelchair the chair tipped backwards and the Resident hit his/her head. The report indicated that the CNA put the Resident back to bed and called the nurse for assessment. The Resident was transferred to the emergency room and received 8 staples for a laceration to his/her head and had a fractured right wrist. During interview with the Director of Nurses on 6/24/16 at 1:30 P.M., the Director said the CNA had been aware that 2 staff must be present when the mechanical lift was used for transfers and that the CNA had chosen to not follow the plan of care and protocol during the transfer of Resident #23. The Director said the Staff Development Coordinator was not available for interview, but she was able to provide statements of the investigation confirming that the CNA's actions had caused injury that would have been prevented if she had followed the plan of care and facility policy by transferring the Resident with 2 staff and not 1. 2. During general observations of the facility on 6/21/16 at 9:00 A.M. and during subsequent observations, the Surveyor observed facility areas that were not free of accident hazards. On 6/21/16 at 9:00 A.M. and on 6/23/16 8:35 A.M., the Surveyor observed that a number of windows, that were located in 2 common areas on the Dementia Special Care Unit (DSCU), were unlocked and could be easily opened to a height that was greater than the requirement of 4 inches. The DSCU was located on the third floor of the building, with windows facing a parking lot and and outside grounds. The windows did not have secured locks in place. During interview on 6/23/16 at 9:00 A.M. the Maintenance Director said that the windows had contained stoppers, but that something must of happened and they got pulled out. He said he put the stoppers in when the facility opened the unit several years ago. He said he had not been made aware of the problem and would address the windows. 3. During general observations on 6/23/16 at 8:30 A.M., with Unit Manager # 4, the Surveyor observed the electrical closet and the clean and dirty utility rooms unlocked. The clean utility room housed the treatment cart (which was unlocked) and other supplies that if left unsecured posed a hazard to the residents. The treatment cart contained resident topical prescriptions, which included multiple containers of bacitracin, nystatin powder, hydrocortisone, and other topical ointments. In addition, the cart contained staple remover kits and treatment supplies. The clean utility room contained unlocked cabinets that had saline solution, enema supplies, mouthwash, razors and wound supplies (which included topical gels). The electrical closet was unlocked and provided access to electrical panels. The unlocked dirty utility closet contained soiled linen, biohazards and hygiene products (lotions, shampoos etc.). During the tour and observation with UM #4, the Maintenance Director joined the tour. The doors to each of the areas had a key pad lock and the Maintenance Director was informed that the doors had been found unlocked. The Maintenance Director looked at the doors and pulled them shut. The doors were pulled on by the Surveyor and the door re-opened. The Maintenance Director said he would look at the doors and either repair the keypad or change the locking system. Subsequent to the tour on 6/23/16, the Surveyors observed the doors to the clean and dirty utility unlocked on 3 other occasions. On 6/23/16 at 8;58 A.M. and 10:30 A.M., the clean utility room was unlocked and accessible. On 6/27/16 at 11:00 A.M., the dirty utility room was unlocked and accessible to residents. The Surveyor notified the Unit Manager (#4) and the Maintenance Director. The Maintenance Director said he had not changed the locks and would look at the self closing device. Although, the concern had been identified on 6/23/16, the facility failed to address the issues to ensure that accidents were prevented by ensuring the areas were secured and maintained there security.