Every finding on record at Andover Manor Rehab and Nursing

Based on observation and interview, the facility failed to ensure it provided an environment free of potential safety hazards on one of one Dementia Special Care Units (DSCU). Specifically, the facility failed to ensure that a closet containing cleaning chemicals was kept locked and was not accessible to residents with dementia and wandering behaviors. Findings include:On 1/13/26 at 8:19 A.M., the surveyor observed the housekeeper on the A2 unit open the door marked closet to obtain some supplies, then walked away. The door was unlocked when the housekeeper accessed it. On 1/13/26 at 8:20 A.M., the surveyor was able to gain access to the unlocked closet. Housekeeping chemicals were observed in the closet. At this time there were three residents wandering and ambulating past the closet, up and down the hallway. On 1/13/26 at 8:21 A.M., the surveyor observed the housekeeper go back into the closet, which remained unlocked, for more supplies, then closed the door, leaving the closet unlocked. On 1/15/26 at 7:28 A.M., the surveyor observed a housekeeper on the A2 unit open the closet door, which was unlocked and obtain supplies. She then closed the door. Multiple residents were observed ambulating up and down the hallway at this time. On 1/15/26 at 7:44 A.M., the surveyor was able to access the unlocked closet and observed multiple housekeeping chemicals stored in the closet. During an interview on 1/15/26 at 7:45 A.M., Unit Manager #2 said that the closet should be locked at all times because of residents on the unit who wander and could potentially open the door and gain access to the chemicals. During an interview on 1/15/26 at 9:43 A.M., the Infection Preventionist said that the closet on the unit, containing housekeeping chemicals should be locked at all times because residents wander on that unit and go into rooms and areas that are not theirs. During an interview on 1/15/26 at 10:50 A.M., the Administrator said that the closet that houses cleaning chemicals should be locked at all times.

Based on observation, record review and interview, the facility failed to provide a dignified environment for one Resident (#77) out of a total of 32 sampled Residents. Specifically, the facility failed to ensure staff did not store personal items in Resident #77's room. Resident# 77 was admitted to the facility in May 2025 with diagnoses including Alzheimer's disease and vascular dementia. Review of the Minimum Data Set Assessment (MDS) 12/8/25 indicated Resident #77 is severely cognitively impaired evidenced by a score of 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. Resident #77 was unable to participate in the interview process. On 1/13/26 at 8:23 A.M., the surveyor observed Resident #77 asleep in his/her bed. Resident #77 did not have a roommate, but a tote bag with two fleece shirts draped on top of it was observed on the unoccupied bed's night table. On 1/14/26 at 7:39 A.M., and on 1/15/26 at 7:23 A.M., the tote bag and fleece shirts were observed on the top shelf of the closet in Resident #77's room. On 1/15/26 at 8:45 A.M., the Assistant Director of Nursing (ADON) and the surveyor observed Certified Nursing Aide (CNA) #1 in Resident #77's room holding the tote bag and taking items out of it. Resident #77 was not in the room at the time. When asked if she keeps her belongings in the Resident's room, CNA #1 said No. I was just looking for something and walked down the hall to place the tote bag at the nurse's station. The ADON said that staff do have areas where they can keep personal belongings and they should not keep personal belongings in resident rooms.

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, on the A2 -unit, a housekeeper failed to implement proper hand hygiene and stored her personal beverage on the housekeeping cart. Findings include:Review of facility policy titled Hand Washing, dated as revised October 25, 2025, indicated the following:-Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination.-Hands should be washed before resident care, after resident care, after breaks, after using the restroom, after smoking or eating, after blowing nose, after disposing of trash, after handling dirty dishes, after picking anything up from the floor, and at any other time deemed necessary. Review of facility policy titled Personal Protective Equipment, dated as revised October 25, 2025, indicated the following:-Policy: to provide guidance for the use and selection of appropriate personal protective equipment (PPE) based on risk of exposure to blood borne pathogen or body fluids, in accordance with state and federal regulations.-Gloves: 5. Immediately wash hands after removing gloves; glove use does not replace hand hygiene. On 1/13/26 at 8:03 A.M., the surveyor observed a housekeeper in the hallway on the A2 unit with gloves on. The housekeeper removed the gloves and did not perform hand hygiene. The Housekeeper then, without performing hand hygiene, went into a resident room after applying a new pair of gloves. With the same pair of gloves on, returned to the housekeeping cart to obtain supplies, the broom and then the mop. At 8:07 A.M., the housekeeper exited the resident room, removed her gloves and used a towel to dry the floor in the hallway. Without performing hand hygiene pushed the housekeeping cart down the hallway, with potentially contaminated hands, to another resident room. Without performing hand hygiene, she entered into another resident room and emptied the trash in the bathroom. Without performing hand hygiene applied another pair of gloves and cleaned the resident room. At 8:13 A.M., the surveyor exited the resident room, removed her gloves and without performing hand hygiene wiped her face and adjusted her clothing before then pushing the cart down the hallway to another resident room with potentially contaminated hands. Without performing hand hygiene, the housekeeper applied new gloves and then entered the room to clean. On 1/13/26 at 8:32 A.M., a housekeeper was observed on the A2 unit drinking from a bottle that was stored on her housekeeping cart and then placing it back on the cart. On 1/15/26 at 7:26 A.M., the surveyor observed a housekeeper on the A2 unit cleaning the bathroom in the hallway. When finished, she removed her gloves and without performing hand hygiene, took the mop off the cart and mopped the floor in the bathroom. At 7:29 A.M., without performing hand hygiene, applied a new pair of gloves and moved on to clean a bathroom labeled nurses rest room. The housekeeper exited the bathroom with the same gloves on and touched the housekeeping cart in many places then obtained a trash bag for the bathroom. At 7:32 A.M., the housekeeper exited the bathroom, removed her gloves and without performing hand hygiene, and with potentially contaminated hands, pushed the housekeeping cart down the hall to clean a room labeled office. Without performing hand hygiene, applied gloves and entered the room to clean. She exited the room, removed her gloves, and without performing hand hygiene, went to the dining room to mop up a spill on the floor. On 1/15/25 at 7:46 A.M., the surveyor observed the housekeeper push the cart down the hallway to a resident's room. The housekeeper was observed blowing her nose into a tissue, and without performing hand hygiene or applying gloves, went into the resident room to open the blind in the room with potentially contaminated hands. She then emptied the trash in the bathroom with ungloved hands and brought the trash to the housekeeping cart. Then, without performing hand hygiene, she applied gloves and entered the resident room to clean. During an interview 1/15/26 at 9:41 A.M., the Infection Preventionist said that staff should be changing gloves between resident rooms and performing hand hygiene in between glove changes in an effort to stop the spread of any infections. She said that the expectation is hand hygiene when entering and exiting a resident room and before and after all glove changes. She further said that the housekeeper should not be storing personal drinks on the housekeeping cart. During an interview on 1/15/26 at 11:38 A.M., the Director of Nurses said that she would expect staff to follow the policy regarding hand hygiene and glove use.

Based on observation, record review and interview the facility failed to accurately document in the medical record for two Residents (#40 and #72) out of a total sample of 32 residents. Specifically for Residents #40 and #72 the facility failed to accurately document that oxygen (O2) tubing and humidification bottles were changed as ordered. Findings include:Review of the facility policy titled Charting and Documentation dated revised 10/25/25 indicated that each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons.1. Resident #40 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease, lung cancer and heart failure.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #40 was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #40 was dependent on staff for activities of daily living and was receiving oxygen therapy.Review of the physician's orders dated December 2025, and January 2026 indicated the following orders:-Oxygen at 2 L/min (liters per minute) via Nasal Cannula to keep O2 > 90% every shift.-O2 (oxygen) Tubing: Change Tubing On Sunday 11-7 &PRN (as needed) for Infection Control Change every Sunday when in use. -On 1/13/26 at 8:13 A.M., the surveyor observed Resident #40 lying in bed receiving oxygen via nasal cannula at 2L/minute. The surveyor also observed that the oxygen humidification bottle and tubing were dated 12/29/25. Review of the Medication Administration Record dated January 2026 indicated that on 1/4/26, the nurse inaccurately signed that the oxygen tubing and humidifier bottle were changed as ordered.During an interview on 1/13/26 at 8:13 A.M., Nurse #2 said that the tubing and bottle should have been changed last week.2. Resident #72 was admitted to the facility in May 2024 with diagnoses including respiratory failure and sleep apnea.Review of the Minimum Data Set assessment dated [DATE], indicated that Resident # 72 was cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #72 required assistance with activities of daily living and was receiving oxygen therapy.Review of the care plan dated as revised 10/29/25 indicated the following focus: I currently have an alteration to my Respiratory System d/t DOE (dyspnea on exertion), acute hypoxia, may need to use oxygen. Further review indicated an intervention to clean equipment per facility protocol. Review of the physician's orders dated December 2025, and January 2026 indicated the following orders:-Oxygen supplemental at 2L (liters) via nasal cannula to maintain O2 (oxygen) sats > 90%.-O2 Tubing: Change Tubing on Sunday night and PRN (as needed) every night shift, every Sun (Sunday) for Infection Control AND as needed for Infection Control, Change every Sunday night when in use.On 1/13/26 at 8:45 A.M., the surveyor observed Resident #72 sitting next to the bed with oxygen via nasal cannula, running at 2L (liters) per minute. The surveyor observed that the oxygen humidification bottle and tubing were dated 12/29/25. During an interview on 1/13/26 at 8:45 A.M., Resident #72 said that the staff have not changed the bottle and tubing for a long time.Review of the Medication Administration Record dated January 2026 indicated that on 1/4/26 the nurse inaccurately signed that the oxygen tubing and humidifier bottle were changed as ordered.During an interview on 1/14/26 at 10:54 A.M., the Director of Nursing (DON) said that nurses should not be documenting in the medical record that they had completed a physician's order when they did not.

Based on observation, interview and records reviewed, the facility failed to ensure for one Resident (#12), out of a total sample of 32 residents, a physical therapy evaluation was completed timely.Findings include:Resident #12 was admitted to the facility in July 2025 with diagnoses including pain in the left hip, muscle spasm, arthropathy (joint disorder), osteonecrosis left femur (bone disorder), primary osteoarthritis (joint disease) right shoulder, primary osteoarthritis left shoulder, major depressive disorder, osteoporosis (deterioration of bone tissues), anemia (low oxygen carrying blood cells), limitation of activities due to disability and epilepsy.Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated Resident #12 had no cognitive impairment. The MDS also indicated Resident #12 was dependent on staff for all functional tasks. Section GG of this MDS indicated Resident #12 has functional impairments to his/her range of motion of his/her bilateral upper and lower extremities.During an observation and interview on 1/14/26 at 8:45 A.M., Resident #12 was observed lying in bed. Resident #12 said he/she was getting up into the wheelchair and was able to stand on both legs with staff assistance before he/she was hospitalized in October and said he/she is unable to stand and unable to bend the left leg at all now and said the right leg is also worse. Resident # 12 said he/she has not received any therapy services since he/she was readmitted in October.Review of Resident #12's physician orders indicated the following:-Physical Therapy 5 times per week for 30 days for PT (physical therapy) Evaluation. Therapeutic Exercises, Neuro Re-Ed, Therapeutic Activities, W/C (wheelchair) mngmnt (management)/mobility, Manual Therapy. PT, OT (occupational therapy), ST (speech therapy) Screen, Eval (evaluation) and Treat as Indicated. Dated 9/24/25.-Clarification of OT orders. skilled OT 5 x week x 2 weeks for ADL (activities of daily living) training, therapeutic exercises, and wheelchair management one time only for 2 weeks. Dated 10/9/25.Review of Resident #12's Physical Therapy Evaluation & Plan of Treatment, dated 9/24/25, indicated:Reason for Referral: Pt referred to PT due to limited functional mobility. Pt (patient) would benefit from PT in order to decrease risk of contractures and further loss of ROM (range of motion).Contracture Functional Limitations Present d/t Contracture = Yes; Functional Limitations as Result of Contracture(s): Pt has ROM deficits and severe crepitus to most joints.Is skilled therapy needed to address impairments? = No (Pt would benefit from therapy to decrease risk of worsening contractures and further decrease in ROM.Reason for Therapy: Continued Pt services are necessary in order to assess functional abilities., decrease risk of worsening ROM. To assess need for environmental adaptations, establish and instruct in compensatory strategies and establish and instruct in FMP (functional maintenance programs).Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: Immobility and decrease in level of mobility, limited OOB (out of bed) time, increased pain.Further review of the medical record indicated a Physical Therapy Discharge summary dated the same day as the initial assessment dated [DATE], was signed on 10/6/25 and indicated Resident #12 was discharged to the hospital at the end of September and was readmitted to the facility in early October. The medical record failed to indicate Resident #12 had a physical therapy evaluation completed after he/she was readmitted early in October.Review of progress notes in Resident #12's medical record from 10/7/25 through 1/14/26 failed to indicate any refusal or documented obstacles impacting the physical therapy evaluation.During an interview on 1/15/26 at 12: 34 P.M., Occupational Therapist (OT) #1 said Resident #12 was not evaluated by physical therapy after he/she was readmitted to the facility in early October and said Resident #12 needs physical therapy and should have been evaluated to continue services. During an interview on 1/15/26 at 12:48 P.M., Director of Rehabilitant (DOR) said Resident #12 had an occupational therapy evaluation done but should have been reevaluated by physical therapy when he/she was re-admitted from the hospital in October and said the resident was receiving physical therapy services prior and should have continued with the screening and evaluation upon return.

Based on observation, record review and interview, the facility failed to provide one Resident (#25) with a therapeutic diet as ordered by the physician out of a total sample of 32 Residents. Specifically, the facility failed to ensure that Resident #25 received a Dysphagia Advanced, textured diet as prescribed by the physician.Findings includeReview of the facility policy titled Diet/Fluid/Supplement, dated as revised 4/12/25, indicated but was not limited to:According to the Academy of Nutrition and Dietetics in Massachusetts Long-Term Care regulations, Physicians shall write a diet order in the medical record for each resident, indicating whether the resident is to have a general (regular) or a therapeutic diet. A therapeutic diet is defined as a diet order by the physician as part of a treatment for a disease or clinical condition, to eliminate or decrease certain substances in the diet (e.g., sodium) or to increase certain substances in the diet (e.g., via supplements) or to provide food in a form that the resident is able to eat (e.g., mechanically altered diet) All therapeutic diets shall be medically prepared prescribed and shall be planned or approved by a dietician. Refer to the speech-language pathologist (SLP) if a patient has difficulty chewing/swallowing prescribed food texture and/or liquid consistency.Food Textures/Liquids Consistencies Offered at the Facility: All food textures and liquids consistency are ordered by the resident MD. If a patient is demonstrating difficulty chewing/swallowing the prescribed diet, the speech-language pathologist (SLP) or dietician may modify a patient's food texture and or liquid consistency following a screen or evaluation. Any changes to the diet require a new order from the MD. Food texture options- bolded are the orders and Electronic Medical Record. Mechanical Soft Chopped/Dysphagia Advanced/Soft and Bite Sized IDDSI 6.Review of the facility policy titled Resident Nutrition Status, dated as revised 10/15/25 indicated but was not limited to: Each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt mail service and appropriate feeding assistance.1. Food services and/or nursing personnel will assure that residents are served the correct food.2. Prior to serving the food, the dietary aid/nurse must check the tray card to assure that the correct food is being served to the resident. If there is doubt, the nurse supervisor will check their written physicians order.3. Nursing staff and the clinical dietitian will assess each resident's foods dislikes, and eating habit. They will correct this information on the resident care plan.Review of the Level 6 SOFT AND BITE SIZED guidelines, last reviewed July 2019 (https://www.iddsi.org/images/Publications-Resources/DetailedDefnTestMethods/English/V2DetailedDefnEnglish31july2019.pdf), indicated the following:- No regular dry bread, sandwiches or toast of any kind.- No regular dry bread due to high choking risk.-Soft, tender and moist, but with no thin liquid leaking/dripping from the food.-Ability to chew 'bite-sized' pieces so that they are safe to swallow is required.-Bite-sized' pieces no bigger than 1.5cm x 1.5cm in size.-Food can be mashed/broken down with pressure from fork-A knife is not required to cut this foodFood Characteristics to AVOID: Crust formed during cooking or heading- Crust or skin that forms on food during cooking or after heating, for example, cheese topping; mashed potato. Large or hard lumps of food. Casserole pieces larger than 1.5cmx1.5cm, fruit, vegetable, meat, pasta or other food pieces larger than 1.5 cm x 1.5cm.Resident #25 was admitted to the facility in October 2025 and has diagnoses that include dysphagia (difficulty swallowing), gastro esophageal reflux disease, esophagitis (inflammation of the esophagus), muscle weakness, hemiplegia and hemiparesis (paralysis / weakness on one side of the body) following cerebral infarction affecting left dominant side and cognitive communication deficit.Review of Resident #25's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating intact cognition. The MDS also indicated Resident #25 required a Mechanically altered diet. Further review of the MDS indicated that the Resident requires supervision or touching assistance with eating.Review of Resident #25's medical record indicated the following physician orders:-NAS (No Added Salt) diet Dysphagia Advanced texture, Regular/Thin (0) consistency. Dated 10/29/25. - Aspiration Precautions every shift for Aspiration Precautions Aspiration Precautions- Administered= no signs/ symptoms aspiration; Not administered= signs/ symptoms observed, see progress note. Dated 12/22/25Further review of the medical record indicated a physician order dated 10/17/25, for (NAS) diet Regular texture, Regular/Thin (0) consistency, diet for Diet, was discontinued on 10/29/25 due to increased s/s (signs/symptoms) of dysphagia.On 1/13/26 at 8:38 A.M., the surveyor observed Resident #25 in bed, with his/her breakfast on the overbed table attempting to eat the meal. The Resident had two slices of dry French toast, and one slice of toasted wheat bread on his/her plate and one bowl of oatmeal. The Resident was peeling the crust off the French toast and breaking the French toast into pieces approximately 2 inches in size. There was one syrup packet located on the overbed table. The French toast was dry and did not have syrup on it. Resident #25 said he/she can't swallow food well and can't eat what is given because it is hard.Review of Resident #25's dietary slip dated 1/13/26, indicated: Regular DYS-ADV. (dysphagia soft advanced) NAS (no added salt)/extra gravy on the side. French toast 2 SL (slices) or Pancakes or Muffin when available. Hashbrown 3/8 cup. Oatmeal cereal 4 0Z (ounces). Bread 1 SL. On 1/13/26 at 12:42 P.M., the surveyor observed Resident #25 sitting on the edge of the bed, the lunch meal was on the overbed table, and Resident #25 was attempting to eat the meal. There was one large round dinner roll and one whole chocolate chip cookie on the Residents lunch plate.Review of Resident #25's care plans indicated: Focus: Aspiration precautions r/t (related to) Diet texture alteration, dysphagia. Interventions: Ask family/ care giver about history of choking- food item, when, positioning. Aspiration Precautions. I will be monitored for changes in condition that would require further evaluation and intervention. Monitor/document/report to MD (medical doctor) PRN (as needed) any s/sx (signs/symptoms) of aspiration or dysphagia: choking, 12/22/25.Focus: Weight loss and difficulty swallowing. Interventions: Cut up food prn. Diet to be followed as prescribed. Instruct resident to eat in upright position, to eat slowly, and to chew each bite thoroughly. Keep head of bed elevated at least 45 degrees during meal and for at least 30 minutes afterwards, 10/22/25.Review of Resident #25's Nutrition Assessment conducted by the Registered Dietitian (RD) dated 10/22/25, indicated the following: Diet: NAS (No Added Salt) Diet Texture: Regular Food Likes: broth, extra gravy, soft food ice cream. Food Dislikes: ToastReview of the Dietary Progress note dated 10/22/25, indicated: He/she reports that there is too much food for him/her and can't eat all that is served. He/she also stated he/she has some nausea. Sounds like he/she has h/o (history of) esophageal dysmotility and is requesting softer food, broth and extra gravy on side. Swallowing difficulty 2/2 h/o esophageal strictures a/e (as evidenced) by pt (patient) report that he/she does better with soft food, cut up. Updated preferences, extra gravy broth. Cut up food prn (as needed). Review of the Physiatry progress note dated 10/28/25, indicated: Resident reports he/she has been having difficulty with his/her meals. He/she reports he/she has not been receiving the food that he/she has been requesting. He/she also endorses that the textures of the food have been difficult for him/her given his/her history of strictures and esophageal dilation. He/she states that sometimes he/she has a cough, and hoarseness of his/her voice. He/she states he/she has been eating the bread and leaving the crust. Requesting having broth for his/her meals since that is something he/she could tolerate swallowing stenosis of his/her throat. Assessment and Plan: Dysphagia: Endorsing difficulty tolerating some of the textures with eating, reporting change in his/her vocal quality and cough. He/she has Hx (history of) CVA (stroke), and esophageal stricture, requiring dilation in the past. He/she is currently on regular textured thin liquid diet consistency. Will consult with SLP to evaluate on current textures. Encouraged to sit up 30 minutes after eating. Will continue to monitor closely for any barriers this may pose rehab. Review of the Speech Therapy Discharge summary dated [DATE], indicated: Diet: Soft + Bite Size Dys-Adv (dysphagia advanced). Strategies: To facilitate safety and efficiency, it is recommended that the patient uses the following strategies and/or maneuvers during oral intake: alternation of liquid/solids, second dry swallow and general swallow techniques/precautions upright posture during meals and upright posture > 30mins after meals.During an interview on 1/14/26 at 12:18 P.M., Certified Nursing Assistant (CNA) #1 said Resident #25 eats in his/her room and will ask for different foods if he/she does not like something and said the nurses check the trays before meals are passed out.During an interview on 1/14/26 at 3:15 P.M., the Dietician said Resident #25 requires a dysphagia advanced diet due to his/her swallowing issues and said he/she needs help with cutting up foods. The Dietician said Resident #25 should not be eating dry breads or toast as it is hard to swallow and said the care plan should reflect the diet order. The Dietitian said she would expect staff to check the diet slip and not give Resident #25 whole toast, whole French toast or dinner rolls.During an interview on 1/15/26 at 7:35 A.M., Unit Manager #1 said Resident #25 is on a dysphagia diet because sometimes he/she has difficulty swallowing.During an interview on 1/15/26 at 11:20 A.M., the Director of Nursing (DON) said she expects diet orders to be followed and said the care plan should indicate the dietary needs. The DON said staff must check order to ensure Residents are not given foods that are not appropriate for their dietary needs and said foods not appropriate could cause the resident to choke if he/she can't swallow them.During an interview on 1/15/26 at 1:34 A.M., Nurse Practitioner (NP) #1 said staff should be following dietary orders and recommendations and said she expects the meal trays to be checked prior to ensuring the foods are appropriate.

Based on interview and record review the facility failed to provide dental services to one resident (Resident #17) of 32 sampled residents. Specifically, the Dentist recommended replacement dentures, and the facility did not review or implement the recommendation. Findings include: Resident #17 was admitted to the facility in July 2021 with diagnoses that included heart disease and diabetes.Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] indicated he/she did not have broken or loosely fitting full or partial dentures, or mouth or facial pain, discomfort or difficulty with chewing. Resident #17 scored a 15 on the Brief Interview for Mental Status exam, indicating intact cognition.Review of Resident #17's dental care plan dated 3/31/25 indicated the Resident has altered oral/dental health related to lost upper denture and missing/cavity on bottom teeth. Care plan interventions did not indicate replacement of the lost dentures.Review of Resident #17's Dentist note dated 9/5/25 indicated the Resident complained that he/she was having a tough time eating since losing his/her dentures a couple of months ago. The Resident had complete upper denture and lower removable partial denture fabricated at an outside dentist in March 2025. Per the Resident, he/she spoke to the insurance company and was told that they would cover a one-time replacement of the dentures. The Dentist indicated he spoke with the Social Services department staff about the situation. The Dentist recommended fabrication of complete upper dentures and lower removable partial dentures to improve the Resident's ability to chew and quality of life. The Dentist recommend full mouth X-rays. The Dentist indicated he reviewed the recommendations with a staff nurse. The Dental note indicated: Action Required by Nursing Home Staff Recommended treatment. New Fabrication of partial lower denture; Fabrication of full upper denture.Review of Resident #17's medical record indicated there was no reference to the Dentist's recommendation and no indication dentures were ordered. Review of correspondence between the facility and the Dentist's office dated 1/15/26 indicated the Dentist's office was unaware the Dentist recommended a replacement set of dentures.During an interview on 1/13/26 at 9:27 A.M., Resident #17 said he/she lost his/her dentures at the facility several months ago. The Resident said somebody told him/her that insurance would not cover the loss for another five years. The Resident said he/she could not afford to pay out-of-pocket for replacement dentures.During an interview with Family Member #1 on 1/14/26 at 11:43 A.M., she said several months ago Resident #17 left his/her dentures on a meal tray wrapped in a napkin. She said a staff member removed the tray and the dentures were subsequently lost. Family Member #1 said the Resident could not afford to pay for replacement dentures and so has gone without them. Family Member #1 said staff are aware of the loss, but the facility did not offer to pay for replacement dentures. During an interview with Nurse #6 on 1/13/26 at 10:05 A.M., she said she recalled that Resident #17's dentures were missing. Nurse #6 said she and other staff looked everywhere but were unable to locate them. Nurse #6 said she did not know whether the Resident or facility staff ordered replacement dentures, or if there was a dental recommendation for new dentures. During an interview with the Director of Social Services on 1/15/26 at 8:41 A.M., he said he was unaware of a dental recommendation for Resident #17 to have new dentures fabricated.During an interview with the Director of Nursing (DON) on 1/14/26 at 10:45 A.M., she said she was unaware Resident #17 was missing dentures. The DON said the facility will pay for replacement dentures if the insurance company will not.

Based on observation, record review and interview, the facility failed to: 1. Ensure medications and biologicals were labeled in one out of four medication carts.2. Ensure medications were stored securely for one Resident #38 out of a total sample of 32 residents. Findings include:1. On 1/15/26 at 8:25 A.M., the surveyor observed the following in the medication cart on the A3 unit:One Anoro Ellipta inhaler (used to treat asthma) open and not labeled with a date. Review of the pharmacy label indicated the inhaler was dispensed 11/5/25. Review of the manufacturer's directions indicated the inhaler is to be discarded 6 weeks after opening. One Anoro Ellipta inhaler dated as opened on 11/16/25 inside a box dated as opened 10/31/25. Review of the pharmacy label indicated the inhaler was dispensed 10/30/25. Review of the manufacturer's directions indicated the inhaler is to be discarded 6 weeks after opening. During an interview on 1/15/26 at 8:25 A.M., Nurse #3 said that the inhalers should be labeled accurately. 2. Review of the facility policy titled Administering Medication, dated as revised 10/15/25, indicated that medications may be self-administered by residents who have been assessed and determined to be safe and upon physician's order. Further review indicated that self-administration of drugs is permitted when approved by the attending physician and the interdisciplinary care planning team. Resident #38 was admitted to the facility in October 2021 with diagnoses including presence of a pacemaker, atrial fibrillation and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 10/8/25, indicated Resident #38 was cognitively intact scoring a 13 out of 15 on the Brief Interview of Mental Status exam. Further review indicated Resident #38 required supervision to partial assistance with activities of daily living. On 1/13/26 at 8:00 A.M., and 4:10 P.M., the surveyor observed a bottle of Fluticasone nasal spray on Resident #38's nightstand. On 1/14/26 at 8:05 A.M., and 4:10 P.M., the surveyor observed a bottle of Fluticasone nasal spray on Resident #38's nightstand. Review of the physician's orders dated January 2025 indicated an order for Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for nasal discomfort. Further review failed to indicate an order for the self-administration of medication. Review of the medical record failed to indicate an assessment for the ability to self-administer medications and store medications safely in the Resident's room. During an interview on 1/14/26 at 8:07 A.M., Nurse #2 said that if the Resident does not have a doctor's order to self-administer the medication, then it should not be in the Resident's room. During an interview on 1/14/2026 at 10:54 A.M., the Director of Nursing (DON) said that it is her expectation that a resident is assessed for the ability to self-administer medications and that a physician's order is obtained before a resident is able to self-administer medications and store safely in their room. The DON then said that all medications are to be stored safely and locked when not using.

Based on observation, record review and interview, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for three Residents (#40, #72 and #15) out of a total sample of 32 residents. Specifically:1. For Resident #40 the facility failed to ensure oxygen tubing and humidification bottle was changed and dated.2. For Resident #72, the facility failed to ensure oxygen tubing and humidification bottle was changed and dated.3.For Resident #15, the facility failed to ensure nebulizer equipment and tubing was changed/dated and b) failed to ensure the oxygen concentrator filter was cleaned.Findings include: Review of the facility policy titled Oxygen Administration and Storage dated revised 10/25/25 indicated that the humidifier bottle is to be labeled with the date of application and changed weekly if refillable. If it is disposable . it is to be changed at least weekly . Further review indicated that the nasal cannula should be changed weekly or more often if soiled. 1. Resident #40 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease, lung cancer and heart failure. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #40 was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #40 was dependent on staff for activities of daily living and was receiving oxygen therapy. Review of the physician's orders dated December 2025, and January 2026 indicated the following orders: -Oxygen at 2 L/min (liters per minute) via Nasal Cannula to keep O2 > 90% every shift. -O2 (oxygen) Tubing: Change Tubing On Sunday 11-7 &PRN (as needed) for Infection Control Change every Sunday when in use. On 1/13/26 at 8:13 A.M., the surveyor observed Resident #40 lying in bed receiving oxygen via nasal cannula at 2L/minute. The surveyor also observed that the oxygen humidification bottle and tubing were dated 12/29/25. During an interview on 1/13/26 at 8:13 A.M., Nurse #2 said that the tubing and bottle should have been changed last week. 2. Resident #72 was admitted to the facility in May 2024 with diagnoses including respiratory failure and sleep apnea. Review of the Minimum Data Set assessment, dated 10/15/25, indicated that Resident # 72 was cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #72 required assistance with activities of daily living and was receiving oxygen therapy. Review of the care plan, dated revised 10/29/25, indicated the following focus: I currently have an alteration to my Respiratory System d/t (due to) DOE (dyspnea on exertion), acute hypoxia, may need to use oxygen. Further review indicated an intervention to clean equipment per facility protocol. Review of the physician's orders dated December 2025, and January 2026 indicated the following orders: Oxygen supplemental at 2L (liters) via nasal cannula to maintain O2 (oxygen) sats > 90%. O2 Tubing: Change Tubing on Sunday night and PRN (as needed) every night shift, every Sun (Sunday) for Infection Control AND as needed for Infection Control, Change every Sunday night when in use. On 1/13/26 at 8:45 A.M., the surveyor observed Resident #72 sitting next to the bed with oxygen via nasal cannula, running at 2L (liters) per minute. The surveyor observed that the oxygen humidification bottle and tubing were dated 12/29/25. During an interview on 1/13/26 at 8:45 A.M., Resident #72 said that the staff have not changed the bottle and tubing for a long time. During an interview on 1/14/26 at 10:54 A.M., the Director of Nursing (DON) said that she expects that the oxygen tubing and humidification bottle are changed according to physician's orders. Review of the facility policy titled Oxygen Administration and Storage, dated as revised 10/25/25, indicated but was not limited to: To ensure staff follow safety guidelines and regulation for storage and use of oxygen. Procedure: 1.Verify provider's order for the procedure. 10. Turn on oxygen and set the flow rate to prescribed amount. Only a nurse may set the flow rate. 12. Label the tubing connected to the oxygen cylinder with time and date. 15. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Humidification as ordered by provider. General Guidelines 4. The nasal cannula or mask should be changed weekly or when soiled. 5. The extension tubing (the tubing used to lengthen the cannula but is not connected directly to the resident) should be changed monthly or when soiled. 6. Nasal cannula and/or mask should be stored in a manager to prevent from touching the floor when not in use. If the mask or nasal cannula touches the floor it should be changed to prevent pathogens from entering the respiratory system. 7. The humidifier bottle is to be labeled with the date of application and change weekly if refillable. If it is disposable (single use) humidification bottle is to be changed at least weekly and more frequently as it near empty or to maintain humidification. 8. Filters should be removed and cleaned by rinsing with clear cool water weekly to maximize flow rate of clean air. 3a. Resident #15 was admitted to the facility in July 2025 with diagnoses including, chronic obstructive pulmonary disease, chronic systolic congestive heart failure, chronic respiratory failure with hypoxia Review of the most recent Minimum Data Set (MDS) assessment, dated 10/29/25, indicated the Resident scored a 10 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. On 1/13/26 at 8:55 A.M., the surveyor observed a nebulizer mask placed partially inside a plastic bag. The mask was dated ''12/29 and written in black ink directly on the face mask, however the tubing and plastic bag were undated. On 1/13/26 at 12:15 P.M., the surveyor observed a nebulizer mask placed partially inside a plastic bag. The mask was dated ''12/29 and written in black ink directly on the face mask, however the tubing and plastic bag were undated. Review of Resident #15's Oxygen care plan dated 7/29/25, indicated the following: -Clean equipment per facility protocol. -My Oxygen tubing and mask/nasal cannula every Sunday 11-7. [sic] Further review of Resident #15's care plans failed to indicate the use of nebulizer treatments. Review of Resident #15's active physician orders indicated the following: -Ipratropium- Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or Wheezing Pretreatment evaluation in supplemental documentation. In progress note document response to instructions and education and any adverse reactions. Notify the provider of any adverse reactions. Start Date: 7/31/25. Review of Resident #15's medical record including Treatment Administration Record (TAR) and Medication Administration Record (MAR) for the month of January indicated the order for Ipratropium- Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours as needed for SOB or Wheezing was documented as administered on 1/12/26. Review of Resident #15's medical record failed to indicate a physician's order or care plan for the care of the nebulizer machine, including tubing or mask, was developed or implemented. During an interview on 1/14/26 at 9:22 A.M., Unit Manager #1 said the nebulizer mask and tubing should be cleaned and changed weekly and said the mask should be stored fully inside the bag and dated. During an interview on 1/14/26 at 10:58 A.M., the Director of Nursing (DON) said respiratory equipment must be cleaned and changed weekly and said she would expect orders and care plans to but updated and followed for the care of the respiratory equipment. 3b. For Resident #15, the facility failed to ensure oxygen concentrator filter was cleaned or changed as necessary. On 1/13/26 at 8:55 A.M., the surveyor observed Resident #15 wearing an oxygen nasal cannula. The oxygen filter on the concentrator was covered with a thick coating of dust. On 1/13/26 at 12:15 P.M., the surveyor observed Resident #15 wearing an oxygen nasal cannula. The oxygen filter on the concentrator was covered with a thick coating of dust. Review of Resident #15's Oxygen care plan dated 7/29/25, indicated the following: -Clean equipment per facility protocol. Review of Resident #15's active physician orders indicated the following: - Oxygen at 3L/min via Nasal Cannula continuously with Humidification every shift related to chronic obstructive pulmonary disease, unspecified. Start Date: 7/30/25. Review of Resident #15's medical record including Treatment Administration Record (TAR) and Medication Administration Record (MAR) for the month of January indicated the order for Oxygen at 3L/min via Nasal Cannula continuously with Humidification every shift was documented as administered daily as ordered. Review of Resident #15's medical record failed to indicate a physician's order or care plan for the care of the oxygen concentrator, was developed or implemented. During an observation and interview on 1/14/26 at 9:20 A.M., the surveyor and Unit Manager #1 observed Resident #15 in bed wearing an oxygen nasal cannula, the oxygen tubing was dated 1/13/26. UM #1 observed the oxygen filter, and said the filter needs to be cleaned and said there should not be a thick layer of dust on the filter. UM #1 said the filter should be cleaned weekly. During an interview on 1/14/26 at 10:57 A.M., the Director of Nursing (DON) said the filter to the oxygen concentrator must be cleaned weekly and documented in the medical record.

Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents. Specifically, the facility failed to provide assistance with showers for two Residents (#64 and #12) out of a total sample of 32 Residents.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated as revised 12/5/25, indicated but was not limited to the following: 1. Residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently will receive the service is necessary to maintain good nutrition, grooming and personal oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with their residents' assessed needs, preferences, stated goals, and recognized standards of practice 7. The residents' response to interventions will be monitored evaluated and revised as appropriate. 1. Resident #64 was admitted to the facility in December 2024 with diagnoses which included hemiplegia, and diabetes. Review of Resident #64's Minimum Data Set (MDS) assessment, dated 12/3/25, indicted a Brief Interview for Mental Status score of 13 out of 15, signifying intact cognition. In addition, the MDS indicated the Resident was dependent on staff for showers and baths, and he/she rejected care one to three days per week. Review of Resident #64's care plan for activities of daily living (ADL) indicated he/she was dependent on staff for most ADL care. During an interview on 1/13/26 at 8:20 A.M., Resident #64 was lying in bed wearing a hospital gown and eating breakfast. The Resident was not malodorous, and his/her hair was covered by a towel. The Resident said he/she prefers to have a shower rather than a bed bath, but it has been over a year since staff gave him/her a shower. Resident #64 said that when he/she asks for a shower staff tell him/her there is not enough time. Resident #64 said he/she believes that because he/she has hemiplegia (paralysis on one side of the body) and it takes time and two staff to transfer him/her, staff avoid giving him/her showers. Review of Resident #64's December 2025 and January 2026 shower schedules indicated he/she was to have a shower every Friday during the 3:00 P.M. to 11:00 P.M. shift. The schedule indicated that staff did not give Resident #64 a shower for the past three weeks (12/26/25, 1/2/26, or 1/9/26). The schedule failed to indicate that the Resident refused a shower or was unable to have a shower. Review of Resident #64's progress notes dated December 2025 and January 2026 and Treatment Administration Records for December 2025 and January 2026 failed to indicate that the Resident refused to be bathed or showered. Review of Resident #64's Certified Nurse Aide (CNA) assignment for January 2026, indicated CNA #3 and CNA #4 were scheduled to give the Resident showers on 1/2/26 and 1/9/26. The surveyor attempted to contact CNA #3 and CNA #4 by telephone on 1/20/26 at 9:18 A.M. and 9:20 A.M. respectively. Voice mail messages were left but as of the completion of this survey there was no response. During an interview with Nurse #6 on 1/14/26 at 8:10 A.M., she said she was unaware that Resident #64 had been asking staff for a shower, or that staff had not bathed him/her for the past three weeks. Nurse #6 said it was the responsibility of the aide to tell the nurse if a resident declines a shower or bed bath. Nurse #6 said a nurse would then document the refusal in the chart, either as a progress note or on the Treatment Administration Record. Nurse #6 said that if the Resident preferred to have a shower, then staff should accommodate him/her. 2. Resident #12 was admitted to the facility in July 2025 with diagnoses that include but not limited to asthma, depression, iron deficiency anemia (low red blood cells), pain in left hip, muscle spasm, arthropathy, osteonecrosis (bone disease), left femur, primary osteoarthritis, right shoulder, primary osteoarthritis left shoulder, major depressive disorder, osteoporosis, anemia (low oxygen carrying blood cells), limitation of activities due to disability and epilepsy. Review of Resident #12's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated Resident #12 was cognitively intact. The MDS also indicated Resident #12 was dependent on staff for all functional tasks. During an interview on 1/14/26 at 8:45 A.M., Resident #12 told the surveyor that he/she has not had a shower in months and would like one and said the facility did not have a shower chair he/she could sit in that would fit into the shower. Review of Resident #12's ADL self-care performance care plan dated as revised on 8/10/25, indicated, I currently have an alteration to my ability to care for self and need assistance d/t (due to) Decrease strength and endurance, Depression, Pain, Weakness. The care plan interventions indicated: -TRANSFER: (Resident) is Extensive Assistance on 2 staff for transferring. The care plan failed to indicate the level of assistance needed for showers. Review of the shower schedule for Resident #12's unit indicated that Resident #12's scheduled shower day was scheduled for Thursday, during the 7:00 A.M to 3:00 P.M., shift. Review of the shower and bathing documentation records for the months of July 2025 through January 2026, failed to indicate any documented showers for Resident #12, and also failed to indicate that the Resident had refused any showers. During an interview on 1/14/26 at 8:38 A.M., Certified Nursing Assistant (CNA) #1 said Residents have scheduled shower days and CNA's document in the electronic medical record when care is provided. When asked about Resident #12, she said Resident #12 does not take showers, just bed baths because it is too hard to get him/her into the shower chair. During an interview on 1/15/26 at 9:07 A.M., Unit Manager #1 said any resident who would like to take a shower, should be provided with a shower. Unit Manager #1 said if the resident refuses a shower, then the CNAs should be documenting that. Unit Manager #1 continued to say the nursing unit had a recent renovation and that the shower chair that Resident #12 needed was able to fit into the shower located on another unit, but said staff could have taken Resident #12 to the other shower.

Based on record review and interview the facility failed to develop and implement a comprehensive care plan for one Resident (#38) out of a total sample of 32 residents. Specifically, the facility failed to develop and implement a comprehensive plan of care for a pacemaker. Findings include: Review of the facility policy titled Comprehensive care Plan, dated as revised 10/25/25, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Review of the facility policy titled Pacemaker Function and Testing, dated as revised 10/25/25, indicated results of testing should be documented in the medical record. Resident #38 was admitted to the facility in October 2021 with diagnoses including presence of a pacemaker, atrial fibrillation and congestive heart failure. Review of the Minimum Data Set assessment, dated 10/8/25, indicated that Resident #38 is cognitively intact, scoring a 13 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #38 required supervision to partial assistance with activities of daily living. Review of the physician's orders dated January 2025 failed to indicate an order for the care of the pacemaker. Review of the Care plan failed to indicate the type of pacemaker, the programed heart rate and the baseline blood pressure. Further review indicated that pacemaker checks are to be completed every 12 months at the cardiologist's office. Review of the facility document titled Report of Consultation, dated 10/18/24, indicted that Resident #38 was scheduled to be sent to a cardiologist for a pacemaker check however, the document was blank other than the Resident's name, date and that the reason was for a pacemaker check. No results were documented. Review of the medical record failed to indicate Resident #38 was sent to the cardiologist every 12 months. During an interview on 1/14/26 at 10:54 A.M., the Director of Nursing (DON) said that she expects that when the facility sends a resident out for a consultation, including a pacemaker check, that there would be documentation in the medical record of the results of the consultation.

Based on observation and interview, the facility failed to ensure one Resident (#12), out of a total sample of 32 residents had a bed that was in operating condition. Specifically, Resident #12 was unable to raise the head of the bed to sit at an upright position.Findings include:Resident #12 was admitted to the facility in July 2025 and has diagnoses that include but not limited to asthma, PTSD (post-traumatic stress disorder), depression, iron deficiency anemia (low red blood cells), pain in left hip, muscle spasm, arthropathy, osteonecrosis, left femur, primary osteoarthritis, right shoulder, primary osteoarthritis left shoulder, major depressive disorder, osteoporosis, anemia (low oxygen carrying blood cells), limitation of activities due to disability and epilepsy.Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated Resident #12 had no cognitive impairment. The MDS also indicated Resident #12 was dependent on staff for all functional tasks.On 1/13/26 at 12:20 P.M., Resident #12 was observed eating lunch in bed. The head of the bed was raised, and Resident #12 was sitting in a semi-sitting position, the head of the bed was in a low fowlers position (approximately 15-30 degrees).On 1/14/26 at 8:47 A.M., Resident #12 was observed eating breakfast in bed. The head of the bed was raised, and Resident #12 was sitting in a semi-sitting position, the head of the bed was in a low fowlers position (approximately 15-30 degrees). Resident #12 said he/she does not get out of bed much and said it would be easier to eat if the head of the bed went up higher, but it does not. Resident #12 showed the surveyor the bed remote and pressed the button on the remote to raise and lower the head of the bed. The bed did not move any higher when the Resident pressed the arrow indicating the up position. Resident #12 said he/she is supposed to keep his/her head of the bed raised and told the surveyor he/she had a choking incident recently and sometimes has shortness of breath.On 1/14/26 at 12:12 P.M., Resident #12 was observed eating lunch in bed. The head of the bed was raised, and Resident #12 was sitting in a semi-sitting position, the head of the bed was in a low fowlers position (approximately 15-30 degrees).Review of the nursing progress note dated 1/5/26 indicated: Change in Condition s/p (status post) choking episode: Pt. (patient) resident in bed denies pain or discomfort head @ 45 degrees in bed stated I want to keep my head up, tolerated meds and food well this shift. [sic]On 1/15/26 at 7:20 A.M., Resident #12 was observed sitting up in bed. The head of the bed was raised, and Resident #12 was sitting in a semi-sitting position, the head of the bed was in a low fowlers position (approximately 15-30 degrees).Review of Resident #12's active physician orders on 1/13/26, indicated:-Head of bed elevated at __ degrees as needed for Shortness of breath while lying flat every shift for Shortness of Breath Head of bed elevated. Start Date: 7/7/25.The physician order failed to indicate an elevation degree and was left blank.Review of Resident #12's January 2026 Medication Administration Record indicated that Resident #12's scheduled physician order was documented. During an interview and observation on 1/15/26 at 7:23 A.M., the surveyor along with the Director of Maintenance observed Resident #12's bed. The Director of Maintenance tried raising the head of the bed and checked the setting located under the bed and said Resident #12's head of the bed does not go any higher. The Director of Maintenance said Resident #12's head of the bed should be able adjust to a higher position so the Resident can sit upright. The Residents bed and the headboard distance was approximately ten inches. The surveyor and the Director of Maintenance then observed a different bed of the same make and model. The Maintenance Director checked the settings under the bed to confirm they were the same as Resident #12 and was able to raise the head of the bed to a higher position. The Residents bed and the headboard distance was approximately 14 inches. He said there could be an issue with motor not raising the head of the bed all the way. The Director of Maintenance said Resident #12's bed should be replaced. During an interview on 1/15/26 at 12:22 P.M., The Director of Nurses said she would expect the Resident to be able to raise the head of the bed so he/she can sit upright and said Resident #12 should not be laying back when eating.During an interview on 1/15/26 at 1:10 P.M., The Administrator said she would expect residents to have beds that are in good working condition.

Based on record review and interview, the facility failed to ensure it followed its grievance process for one Resident (Resident #17) out of 32 sampled residents. Specifically, the facility failed to document, investigate and provide a resolution to lost dentures. Findings include:Review of the facility policy Resident and Family Concerns and Grievances, dated as revised 10/5/25, indicated:- The facility Compliance and Ethics Officer or a designated staff will document and keep a log of all grievances expressed either orally and/or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance. Management or supervisory staff will commence a formal investigation of the grievance as soon as practicable and advise the resident of the outcome of the investigation.Resident #17 was admitted to the facility in July 2021 with diagnoses that included heart disease and diabetes.Review of Resident #17's Minimum Data Set (MDS) assessment, dated 10/2/25, indicated he/she did not have broken or loosely fitting full or partial dentures, or mouth or facial pain, discomfort or difficulty with chewing. Resident #17 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition.Review of Resident #17's dental care plan, dated 3/31/25, indicated the Resident has altered oral/dental health related to lost upper denture and missing/cavity on bottom teeth. Care plan interventions did not indicate replacement of the lost dentures.Review of Resident #17's Dentist note, dated 9/5/25, indicated the Resident complained that he/she was having a tough time eating since losing his/her dentures a couple of months ago. The Dentist indicated he spoke with the Social Services department staff about the situation. The Dentist recommended fabrication of complete upper dentures and lower removable partial dentures to improve the Resident's ability to chew and quality of life. The Dentist recommend full mouth X-rays. The Dentist indicated he reviewed the recommendations with a staff nurse. The Dental note indicated: Action Required by Nursing Home Staff Recommended treatment. New Fabrication of partial lower denture; Fabrication of full upper denture. Review of the 2025 and 2026 grievance logs indicated there was no reference to Resident #17's loss of dentures. During an interview on 1/13/26 at 9:27 A.M., Resident #17 said he/she lost his/her dentures at the facility several months ago. The Resident said somebody told him/her that insurance would not cover the loss for another five years. The Resident said he/she could not afford to pay out-of-pocket for replacement dentures.During an interview with Family Member #1 on 1/14/26 at 11:43 A.M., she said several months ago Resident #17 left his/her dentures on a meal tray wrapped in a napkin. She said a staff member removed the tray and the dentures were subsequently lost. Family Member #1 said the Resident could not afford to pay for replacement dentures and so has gone without them. Family Member #1 said staff are aware of the loss, but the facility did not offer to pay for replacement dentures. During an interview with Nurse #6 on 1/13/26 at 10:05 A.M., she said she recalled that Resident #17's dentures were missing. Nurse #6 said she and other staff looked everywhere but were unable to locate them. Nurse #6 said she did not know whether the Resident or facility staff ordered replacement dentures. Nurse #6 said that if a staff member accidentally threw the dentures away then it was the facility's financial responsibility to reimburse the Resident or have new dentures made. Nurse #6 said the loss of dentures should have been recorded in the grievance log and a resolution provided to Resident #17.During an interview with the Director of Nursing (DON) on 1/14/26 at 10:45 A.M., she said she was unaware Resident #17 had missing dentures. The DON said that it is the facility's policy to include missing resident property, such as dentures, in the grievance log and for these losses to be investigated. The DON said the facility will pay for replacement dentures if the insurance company will not.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for 3 Residents (#19, #69 and #106) out of a total of 29 sampled residents. Specifically: 1. For Resident #19 the facility failed to obtain a physician's order for the use of an air mattress, 2. For Resident #69 the facility failed to discontinue a treatment for a healed right ankle, and 3. For Resident #106 the facility failed to ensure an antibiotic used to treat an infection was administered timely for one of two closed records reviewed. Findings include: Resident #19 was admitted to the facility in March 2024 with diagnoses including traumatic subdural hemorrhage, diabetes, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/16/24, indicated that Resident #19 was severely cognitively impaired as evidenced by staff assessment of Brief Interview for Mental Status. The MDS further indicated that Resident #19 had a pressure relieving device to his/her bed. Review of Resident #19's physician's orders, dated 1/7/25, failed to indicate an order for an air mattress to his/her bed. Review of Resident #19's active plan of care, failed to include the interventions of an air mattress to his/her bed. On 1/8/25 at 1:21 P.M. Nurse #1 and the surveyor observed Resident #19 on an air mattress in his/her bed. During an interview on 1/7/25 at 9:04 A.M., Nurse #1 said she would expect a Resident with an air mattress to have a physician's order. During an interview on 1/8/25 at 1:35 P.M., the Director of Nursing said she would expect a Resident with an air mattress to have a physician's order. 36431 2. For Resident #69 the facility failed to adhere to professional standards of practice, when nursing staff provided a treatment two times a day to an ankle wound that was not present on the Resident. Resident #69 was admitted to the facility in August 2021 and has diagnoses that include but are not limited to unspecified dementia, adult failure to thrive, bipolar disorder and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #69 scored a zero out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment. Further, the MDS indicated the Resident is dependent on staff for all aspects of care, is at risk for developing pressure ulcers and does not have any unhealed pressure ulcers. On 1/6/25 at 8:27 A.M., Resident #69 was observed in his/her bed, equipped with a pressure-relieving air mattress. The air mattress setting affixed to the foot board was illuminated and blinking at the top light, under the word 'firm'. Review of Resident #69's medical record indicated the following: -Braden Scale for Predicting Pressure Sore Risk dated, 3/6/24, 4/30/24, 5/21/24, 8/21/24 and 11/22/24 all with a score of 10 indicating Resident #69 as having a high risk for developing pressure sores. -A physician's order, Right ankle: Assess wound and apply skin prep every shift and ensure pressure is off loaded. Every day and evening shift for wound examination, order date 2/2/24. Review of Resident #69's care plans failed to indicate a care plan for any actual open areas, including the right ankle. Review of the weekly skin check dated 1/7/24 indicated no open skin areas and documented a callous hammer toe. During an interview on 1/9/25 at 7:25 A.M., Nurse #7 said Resident #69 had a pressure area on his/her coccyx a while ago and she was not aware of any other wounds. Nurse #7 checked the orders and then asked Certified Nursing Assistant (CNA) #4 if the Resident had a wound. CNA #4 said Resident #69 did not have any wound or skin issues on his/her feet. During an observation and interview on 1/9/25 at 7:33 A.M., Nurse #7, with the surveyor present, examined/observed Resident #69's feet which revealed no wound on his/her right ankle. Nurse #7 said she did not know why a treatment twice a day with skin prep for a wound was on the physician's orders. Nurse #7 said maybe it was pink at one time. During an interview on 1/9/25 at 7:38 A.M., Unit Manager #1 said if a resident is identified with a new skin injury, skin tear, open area or pressure area the Nurse Practitioner/Doctor is notified, a treatment order is obtained, and a skin incident report is completed. Unit Manger #1 said for Resident #69, she did not see a skin area incident report. Unit Manager #1 reviewed the order for the right ankle wound for Resident #69 and said if there is no wound present, she would expect the nurses who are providing the twice daily treatment to report the wound as healed and to have the wound order discontinued. Unit Manager #1 said she would need to investigate the origin of the order more. During an interview on 1/9/25 at 12:51 P.M., Unit Manager #1 said the right ankle treatment was ordered on 2/20/24, said there was no identified area on the weekly skin check, nor note regarding the right ankle wound. 3. Review of the facility's policy entitled, MISCELLANEOUS SPECIAL SITUATION, UNAVAILABLE MEDICATIONS, dated November 2021 indicated: medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure medications are available to meet the needs of each resident. Procedures B. Nursing staff shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. Resident #106 was admitted to the facility in September 2024 and had diagnoses that included but were not limited to unspecified dementia and urinary tract infection. Review of the Nursing Admission Screening V15, with an effective date of 9/20/24 for Resident #106 indicated the following: reason for admission: Rehab/UTI (urinary tract infection), cognition confused with short-term and long-term memory problem. Review of Resident #106's medical record indicated the following: A physician's order dated 9/20/24 with a start date 9/21/24, Cefdinir (an antibiotic medication) Capsule 300 mg (milligrams), Give 1 capsule by mouth two times a day for infection for 5 days. Review of the Medication Administration Record (MAR) dated for September 2024 indicated the administration of the Cefdinir 300 mg was signed off as a 9 (other/see progress note) dated 9/21/24 2000 (8:00 P.M.) dose, 9/22/24 0800 (8:00 A.M.) dose and 9/22/24 2000 (8:00 P.M.) dose. Further review of the MAR indicated Resident #106 had been administered his/her first dose of the antibiotic cefdinir, on 9/22/24 at 2139 (9:39 P.M.) Review of the progress note dated 9/21/24 at 06:44 (6:44 A.M.) note text: Abx (antibiotic) for patient not delivered, f/u (follow up) with pharmacy and said it will be on the run tonight. Review of the progress note dated 9/22/24 at 14:40 (2:40 P.M.) note text: Abx (antibiotic) for patient not delivered, f/u with pharmacy and said it will be on the run tonight. The progress notes failed to indicate that the physician or nurse practitioner were notified that the antibiotic was not administered as ordered. During an interview on 1/7/25 at 11:45 A.M., Nurse #6 said when a new medication is ordered for a resident, including an antibiotic when they return from the hospital, the nurse verifies the order with the Nurse Practitioner (NP)/Medical Doctor (MD) and then the nurse can obtain the medication from the Cubex (an automated pharmacy system) located on the B1 unit. Nurse #6 said if the medication is not available the pharmacy and the NP or MD need to be called, and the NP/MD would review and decide on how to proceed. Nurse #6 said the NP/MD need to be made aware when a medication is not administered as ordered. During an interview on 1/7/25 at 3:33 P.M., Physician #1 said the NP/MD should be notified if an antibiotic is not started for any reason. During an interview on 1/9/25 at 12:39 P.M., the Director of Nursing (DON) said although the nurses documented that the pharmacy was called and the first dose was administered on 9/22/24 when the antibiotic arrived at the facility, the nursing staff should have notified the NP/MD that the antibiotic for Resident #106 was not started as ordered.

Based on observations, interviews and record review, the facility failed to develop and implement person-centered care plans for five Residents (#6, #16, #25, #210 and #23) out of a sample of 29 residents. Specifically, 1. For Resident #6, the facility failed to implement his/her compression socks. 2. For Resident #16, the facility failed implement offloading his/her heels as per the plan of care. 3. For Resident #25, the facility failed to develop a comprehensive pacemaker care plan. 4. For Resident #210, the facility failed to develop personalized behavior care plans. 5. For Resident #23, facility failed to develop a personalized history of substance abuse care plan. Findings include: A review of the facility policy titled 'Comprehensive Care Plan' with a revision date of October 2024 indicated the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. A review of the facility policy titled 'Behavioral Health Services-Including Substance Abuse' with a revision date February 2024 indicated the following: -It is this facilities policy that all residents receive the necessary behavioral health care and services, including substance abuse services, to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 1. Resident #6 was admitted to the facility in July 2022 and has diagnoses that include but are not limited to chronic obstructive pulmonary disease, edema, and chronic systolic (congestive) heart disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating he/she as having moderately impaired cognition. Further, the MDS indicated that Resident #6 was dependent on staff for lower body dressing. On 1/6/25 at 8:00 A.M., Resident #6 was observed in the dining room. He/she was observed to be breathing heavy. Resident #6 said he/she gets short of breath and needs to eat and drink slowly. Review of Resident #6's medical record indicated the following: -A physician's order dated 12/5/24 compression socks on in morning, off night every day and evening shift for prevention. During an observation and interview on 1/7/25 at 8:21 A.M., Resident #6 was in the dining room. He/she was not wearing compression socks. Resident #6 said he/she needs help putting them on. On 1/7/25 at 11:38 A.M., Resident #6 was sitting in his/her wheelchair in the dining room. His/her left leg was observed with a slipper sock and no compression sock. On 1/7/25 at 12:36 P.M., Resident #6 said he/she only had ankle socks on. Resident #6's feet were observed with slipper socks and no compression socks. On 1/7/25 at 3:30 P.M., Resident #6 was in the dining/living room and observed not to be wearing compression stocks, and his/her feet were observed as puffy. On 1/8/25 at 4:22 P.M., Resident #6 said she did not have her compression socks on. Observation of his/her legs revealed the compression socks were not on. Resident #6 said she had a bruise or something on her right foot. On 1/9/25 at 8:36 A.M. Resident #6 was observed being assisted by staff out of the bathroom located across from the elevators. Resident #6 was observed back in the dining room and observed to not be wearing his/her compression socks. Resident #6 was breathing heavily and said she just came from the bathroom. During an interview on 1/9/25 at 8:39 A.M., Certified Nursing Assistant (CNA) #12 said Resident #6 accepts daily care and does not refuse. CNA #12 said Resident #6 wears special stockings. CNA #12 said she did not put them on this morning because Resident #6 was already up when she came in at 7:00 A.M. The surveyor and CNA #12 went to Resident #6's room and found one compression sock. CNA #12 said that Resident #6 has something on his/her heel and maybe cannot wear the compression sock on that foot. CNA #12 said either the CNA or the nurse can put on the compression stocks. During an interview on 1/09/25 at 10:31 A.M., Nurse #14 said Resident #6 has a blister on his/her right heel and may have refused to wear the compression socks. During an interview on 1/9/25 at 10:44 A.M. Unit Manager #1 said the compression socks should be on as ordered. Unit Manager #1 said if the compression socks are not put on per the order the nurse should document why in the medical record. Review of the documentation in Resident #6's medical record failed to indicate any entries regarding Resident #6 not wearing the compression socks. 43846 2. Resident #16 was admitted to the facility in August 2015 with diagnoses that included dementia, dysphagia, adult failure to thrive, and anxiety. Review of Resident #16's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairment. The MDS further indicated the Resident was dependent on staff for eating and all other Activities of Daily Living (ADLs). The MDS further indicated Resident #16 is at risk for pressure ulcers. On 1/6/25 at 7:57 A.M., the surveyor observed Resident #16 in bed with his/her heels flat on the mattress. On 1/7/25 at 6:59 A.M., the surveyor observed Resident #16 in bed with his/her heels flat on the mattress. On 1/9/25 from 7:19 A.M. to 8:06 A.M., the surveyor observed Resident #16 in bed with his/her heels flat on the mattress. During an interview on 1/9/25 at 8:06 A.M., Certified Nurse Aide (CNA) #7 said each resident has a care plan and kardex and staff are expected to follow them. Review of Resident #16's skin breakdown care plan dated, 10/16/23, indicated Off Load/Float heels while in bed. Review of Resident #16's CNA Kardex, dated 1/7/25, indicated Off Load/Float heels while in bed. Review of Resident #16's Braden Scale for Predicting Pressure Sore Risk, dated 10/19/24, indicated he/she scored an 11 indicating he/she is at high risk for developing a pressure ulcer. During an interview on 1/9/25 at 8:03 A.M., Nurse #8 and Nurse #4 said he/she is at risk for skin breakdown and his/her heels should be offloaded while in bed. Nurse #8 and Nurse #4 said nursing staff are expected to follow the Resident care plan and Kardex. 3. Review of the facility policy titled Pacemaker Function and Testing, dated 11/5/24, indicated To ensure pacemaker is functioning properly through nursing assessment resident education and physician notification of abnormalities. The physician shall provide the facility with the specific maximum heart rate above the pacemaker rate that is acceptable. The physician shall provide the programmed lower and upper rate for the pacemaker. Resident #25 was admitted to the facility in December 2023 with diagnoses that included dementia, presence of a cardiac pacemaker, and adult failure to thrive. Review of Resident #25's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Review of Resident #25's readmission assessment, dated 3/13/24, indicated the Resident has a pacemaker. Review of Resident #25's physician order, dated 3/14/24, indicated Pacemaker Apical Pulse Check: Check apical pulse for one minute daily. Pulse rate should be the same as pacemaker rate or faster. Notify physician if pulse is more than 5-10 beats lower than pacemaker's setting. Review of Resident #25's care plan, alteration to my Cardiac System d/t (due to) sick sinus syndrome due to SA node dysfunction for which I recently had a pacemaker placed care plan, dated 3/14/24, indicated has a Pacemaker: Manufacturer: (SPECIFY) Model: (SPECIFY) Serial #: (SPECIFY) Date implanted: (SPECIFY, if known) Name of cardiologist: (SPECIFY). Monitor pulses as ordered and PRN. Report abnormalities to MD (medical doctor). My pacemaker will be check per cardiologist orders. Review of Resident #25's Physician Assistant progress note, dated 3/19/24, indicated Permanent pacemaker placed on 3/11/2024. Recommend follow-up with cardiology. During an interview on 1/8/25 at 1:44 P.M., Nurse #5 said Resident #25 does have a pacemaker and said she does not know the pacemaker settings or any other pacemaker information. During an interview on 1/8/25 at 1:48 P.M., the Director of Nurses (DON) said there should be a complete comprehensive care plan for Resident #25's pacemaker. The DON said she would expect the nurses to know the pacer settings to monitor the Resident. 43807 4. Resident #210 was admitted to the facility December 2024 with diagnoses including major depressive disorder, generalized anxiety disorder, delusions and hallucinations. A review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status Score. A review of the Psychiatric Nurse Practitioner's progress note dated 1/6/25 indicated that the Resident is AOx2 (alert and oriented to person and place only). On 1/6/25 at 8:25 A.M., the surveyor observed Resident #210 in bed, his/her right upper arm had bruises and scars. Resident #210 said she picks and digs at the scabbed bruises and opens them up. A review of the discharging hospital shift notes dated 10/30/24 indicated the following: -Skin with multiple scabbed areas in various stages of healing, patient continued to pick and scratch at skin. Review of Resident #210's medical record indicated the following: A review of the skin review dated 12/27/24 indicated the following: -Multiple scabbed areas all over due to bedbugs. A review of the skin review dated 12/31/24 indicated the following: -Scars on the abdomen and limbs from picking per patient. A review of the skin review dated 1/7/25 indicated the following: -Scars on abdomen and limbs from picking' per patient. A review of Resident #210's care plans failed to indicate that the Resident's behavior of skin picking, history of hallucinations and delusions was care planned. During an interview on 1/8/25 at 1:30 P.M., Certified Nurse's Assistant (CNA) #11 said she provided head to toe care to Resident #210 today, she said she saw scars, scabbed areas and open areas on the Resident's body. She said Resident #210 told her he/she picks on his/her skin when he/she gets angry. During an interview on 1/8/25 at 2:23 P.M., Nurse # 13 said Resident #210 was admitted with scabbed areas on his/her body due to a history of bedbugs prior to admission. During a telephone interview on 1/9/25 at 7:50 A.M., the Social Worker said she was not aware of Resident #210's behavior of picking his/her skin, she said his/her history of hallucinations and delusions should be further explored to determine whether the skin picking is a tactile hallucination. The Social Worker said his/her behavior care plans should be developed and individualized. 5. Resident #23 was admitted to the facility in June 2024 with diagnoses including Dementia with psychotic features and behavioral disturbance. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe cognitive impairment. A review of Resident #23's Psychiatric Nurse's progress notes dated 12/30/24 indicated the following: -Substance Use/Abuse based symptoms: history of alcohol abuse. A review of Resident #23's care plan failed to indicate a substance abuse care plan. During a telephone interview on 1/9/25 at 7:42 A.M., The Social worker said Resident #23's cognition might present a barrier for participation in the facility's substance abuse services, but the facility Nursing staff should also be aware that most residents with a history of alcohol use disorder perceive pain more intensely. She said Resident #23's substance abuse care plans should be developed and personalized.

Based on observation and interviews the facility failed to provide a dignified dining experience for several residents on one resident care unit (The dementia care unit), out of three resident units. Findings include: Review of the facility's policy and procedure, titled Dining Room Rounds, dated as revised November 5, 2024, indicated the following: Our facility audits the food services department regularly to ensure that resident needs are being met and that dining is a safe and pleasant experience for residents. Policy Interpretation and Implementation 2. The auditor will assess: d. If residents at each table are served together, f. If adequate staff are available to assist with passing trays, meal set-up, and feeding. During an observation during the breakfast meal service on the dementia care unit the following was observed: On 1/6/25 at 8:38 A.M., table one's first resident received their meal at 8:38 A.M., the next resident did not receive their tray until 8:51 A.M., thirteen minutes later. On 1/6/25 at 8:40 A.M., table three's first resident received their meal at 8:40 A.M., the next resident did not receive their tray until 8:48 A.M., eight minutes later. On 1/6/25 at 8:46 A.M., table four's first resident received their meal at 8:46 A.M., the next resident did not receive their tray until 8:52 A.M., six minutes later. On 1/6/25 at 8:43 A.M., table five's first resident received their meal at 8:43 A.M., the last resident did not receive their tray until 8:49 A.M., six minutes later. The first resident was observed trying to feed his/her table mate. During the lunch meal service on 1/6/24 on the Dementia Care Unit, the following was observed: On 1/6/25 at 12:42 P.M., table two's first resident received their meal at 12:42 P.M., the next resident did not receive their tray until 12:52 P.M. ten minutes later. On 1/6/25 at 12:38 P.M., table three's first resident received their meal at 12:38 P.M., the last resident did not receive their tray until 12:55 P.M. seventeen minutes later. During an interview on 1/6/25 at 9:08 A.M., Nurse #9 said mealtime tray pass is chaotic and the staff do not get help from other floors or other departments. Nurse #9 said that each table should be served in order so the residents at the table do not have to wait to receive their meal.

Based on record review and interviews, the facility failed to report an allegation of abuse to the state agency within the mandated timeframes for two Residents (56 and #23) out of a sample of 29 residents after a resident to resident altercation. Specifically, the facility failed to file a report to the state agency after Resident #23 pinched Resident #56. Findings include: A review of the facility's policy titled 'Resident Right to Freedom from Abuse, Neglect and Exploitation' with a revision date of October 2024 indicated the following: -The Facility's residents have the right to be free from abuse as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. -The Facility shall review altercations from resident to resident as a potential situation of abuse. -Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include but are not limited to, physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures and throwing objects. -When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: -Taking steps to prevent further potential abuse. -Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. -Conducting a thorough investigation of the alleged violation. -Taking appropriate corrective action. A review of a Facility flyer titled 'Abuse Reporting' dated 6/19/23 indicated the following: -Things that need to be reported immediately to the supervisor: -Any bruise, redness or other injury to a resident that you do know how it occurred. -Any resident-to-resident altercation. -Many of these concerns must be addressed and reported to the Department of Public Health within two hours. Resident #56 was admitted to the facility in October 2024 with diagnoses including dementia with behavioral disturbance. A review of the most recent Minimum Data Assessment (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely and never understood. Resident #23 was admitted to the facility in June 2024 with diagnoses including dementia with psychotic features and behavioral disturbance. A review of the most recent Minimum Data Set, dated dated dated [DATE] indicated a Brief Interview for Mental Status score of 3 out of a possible 15 indicating severe cognitive impairment. A review of Nursing progress notes dated 12/6/24 indicated the following: -Resident approached a male/female resident and was talking to him/her close in his face, male/female resident became aggressive and pinched resident on his/her lower left cheek. He/she was escorted out of the room and taken in the supervise room. Administrator, UM (Unit Manager), on call NP(Nurse Practitioner), HCP (Health Care Proxy) notified and explained plan of care and he agreed. He said, My spouse is a very friendly person. During assessment was noted a redness on his/her left lower cheek. NP (Nurse Practitioner) said to monitor residents. [sic] A review of Nursing progress notes dated 12/7/24 indicated the following: -Resident redness subsides by the end of the shift. [sic] A review of the facility event report titled 'physical aggression received' dated 12/6/24 indicated the following: - Resident #56 approached a male/female resident and was talking to him/her close in his/her face, male/female resident became aggressive and pinched resident on his/her lower left cheek. He/she was escorted out of the room and taken in the supervise room. During assessment it was initially noted redness on his/her left lower cheek, but it quickly resolved. [sic] A review of Resident #56's care plan initiated 10/3024 and 12/10/24 respectively indicated the following: -Focus: Resident #56's current risk of wandering/elopement and safety will be monitored every shift by all staff. -Focus: Resident #56 has alteration in behavior status related to restlessness, physical aggression and is resistive to care. Intervention: Approach in a calm manner, divert attention when encroaching on others' personal space, remove from situation and take to alternate location as needed. A review of Resident #23's care plan initiated 7/3/24 and intervention initiated 12/10/24 indicated the following: -Resident #23 has an alteration in behavior status related to anxiety, depression and agitation. Intervention-Assist Resident #23 to develop more appropriate methods of coping and interacting, encourage Resident #23 to express feelings appropriately. During a telephone interview on 1/9/25 at 8:51 A.M., Activity Assistant #3 said on 12/6/24, she was running an activity alone. Activity Assistant #3 said Resident #56 and Resident #23 were in attendance. Activity Assistant #3 said she was seated at a table with two other residents completing a puzzle. Activity Assistant #3 said she was not paying attention to Resident #56 who was wandering around the room and Resident #23 who was seated at a different table watching television. She said Resident #56 approached Resident #23, Resident #56 moved in close to Resident #23's face and started to talk to him/her. Resident #23 became aggressive and pinched Resident #56's left lower cheek. The Activity Assistant said she had to run across the room to separate both Residents. Activity Assistant #3 said she escorted Resident #23 out of the room into the sensory room. She said, as she escorted Resident #56 out of the room, the Resident had his/her hand on his/her left cheek and said it hurt. Activity Assistant #3 said Resident #56 should always be closely supervised if he/she is up, she said the Resident has a history of wandering, getting close in other resident's personal spaces. Activity Assistant #3 said there is not always enough staff to help supervise residents during activities. She said it would be beneficial to have more than one staff during activities with residents with a behavior history. During a telephone interview on 1/9/25 at 9:06 A.M., Nurse #12 said on 12/6/24, Resident #23 was watching television in the Activity room. She said Resident #56 was in the same Activity room, wandering around the room. She said Resident #56 has a history of getting close to other residents, she said he/she got close to Resident #23's face, he/she did not like it, he/she pinched Resident #56's lower left cheek. Nurse #12 said the Activity Assistant brought Resident #56 to her after the incident. She said the Resident was covering the left cheek with his/her hand, saying it hurt. She said the cheek was red for several hours. She said staff should be aware when Resident #56 is up and about, they should closely supervise him/her and be ready to separate him/her when he/she enters other residents' personal spaces. She said based on the flyer hanging on the unit tilted 'Abuse Reporting' the incident should have been reported to the state agency within two hours. During an interview on 1/9/25 at 9:47 A.M., Unit Manager #1 said she was not in the facility when the incident happened between Resident #56 and #23. She reviewed the progress notes and said when incidents such as these happen, the expectation is for staff to redirect the residents involved, assess for injuries, start an investigation and notify the Director of Nurses immediately. She said abuse can be defined as the willful inflicting of harm on another person, she said abuse can happen between residents or staff and residents. She said this type of resident-to-resident altercation should be reported to the state agency within two hours. During an interview on 1/9/25 at 10:14 A.M., the Director of Nurses said on 12/6/24, Resident #56 and #23 were both in an unsupervised common area, she said after the incident occurred, the Residents were redirected to a supervised common area. She said based on Resident #56's behavior history of wandering and getting in other resident's personal spaces, she expects staff to supervise him/her on the unit. The DON said an event report was completed after the incident occurred. She said it was determined that Resident #23's intentions were not to harm Resident #56 even though he/she retaliated aggressively by pinching Resident #56 causing pain on his/her left cheek. The DON said after using the [NAME] navigation tool( This tool was built to help Massachusetts health care providers navigate key state and federal requirements for reporting adverse and other events that affect patient safety). As a facility, they determined that the incident did not need to be reported to the state agency. The DON said reportable abuse events should be reported within two hours to the state agency. A review of the Health Care Facility Reporting System (HCFRS) failed to indicate that the resident to resident altercation was reported.

Based on record review and interviews, the facility failed to prevent a resident-to-resident altercation between two Residents (#56 and #23) out of a sample to 29 residents. Specifically, the facility failed to prevent Resident #23 from pinching Resident #56's left cheek. Findings include: A review of the facility's policy titled 'Resident Right to Freedom from Abuse, Neglect and Exploitation' with a revision date of October 2024 indicated the following: -The Facility's residents have the right to be free from abuse as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. -The Facility shall review altercations from resident to resident as a potential situation of abuse. -Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include but are not limited to, physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures and throwing objects. -When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: -Taking steps to prevent further potential abuse. -Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. -Conducting a thorough investigation of the alleged violation. -Taking appropriate corrective action. A review of a Facility flyer titled 'Abuse Reporting' dated 6/19/23 indicated the following: -Things that need to be reported immediately to the supervisor: -Any bruise, redness or other injury to a resident that you do know how it occurred. -Any resident-to-resident altercation. -Many of these concerns must be addressed and reported to the Department of Public Health within two hours. Resident #56 was admitted to the facility in October 2024 with diagnoses including dementia with behavioral disturbance. A review of the most recent Minimum Data Assessment (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely and never understood. Resident #23 was admitted to the facility in June 2024 with diagnoses including dementia with psychotic features and behavioral disturbance. A review of the most recent Minimum Data Set, dated dated dated [DATE] indicated a Brief Interview for Mental Status score of 3 out of a possible 15 indicating severe cognitive impairment. A review of Nursing progress notes dated 12/6/24 indicated the following: -Resident #56 approached a male/female resident and was talking to him/her close in his/her face, male/female resident became aggressive and pinched resident on his/her lower left cheek. He/she was escorted out of the room and taken in the supervise room. Administrator, UM (Unit Manager), on call NP (Nurse Practitioner), HCP (Health Care Proxy) notified and explained plan of care and he agreed. He said, My spouse is a very friendly person. During assessment was noted a redness on his/her left lower cheek. NP (Nurse Practitioner) said to monitor residents. A review of Nursing progress notes dated 12/7/24 indicated the following: -Resident redness subsides by the end of the shift. A review of the facility event report titled 'physical aggression received' dated 12/6/24 indicated the following: - Resident approached a male/female resident and was talking to him/her close in his face, male/female resident became aggressive and pinched resident on his/her lower left cheek. He/she was escorted out of the room and taken in the supervise room. During assessment it was initially noted redness on his/her left lower cheek, but it quickly resolved. [sic] A review of Resident #56's care plan initiated 10/3024 and 12/10/24 respectively indicated the following: -Focus: Resident #56's current risk of wandering/elopement and safety will be monitored every shift by all staff. -Focus: Resident #56 has alteration in behavior status related to restlessness, physical aggression and is resistive to care. Intervention: Approach in a calm manner, divert attention when encroaching on others' personal space, remove from situation and take to alternate location as needed. A review of Resident #23's care plan initiated 7/3/24 and intervention initiated 12/10/24 indicated the following: -Resident #23 has an alteration in behavior status related to anxiety, depression and agitation. Intervention-Assist Resident #23 to develop more appropriate methods of coping and interacting, encourage Resident #23 to express feelings appropriately. During a telephone interview on 1/9/25 at 8:51 A.M., Activity Assistant #3 said on 12/6/24, she was running an activity alone. Activity Assistant #3 said Resident #56 and Resident #23 were in attendance. Activity Assistant #3 said she was seated at a table with two other residents completing a puzzle. Activity Assistant #3 said she was not paying attention to Resident #56 who was wandering around the room and Resident #23 who was seated at a different table watching television. She said Resident #56 approached Resident #23, Resident #56 moved in close to Resident #23's face and started to talk to him/her. Resident #23 became aggressive and pinched Resident #56's left lower cheek. The Activity Assistant said she had to run across the room to separate both Residents. Activity Assistant #3 said she escorted Resident #23 out of the room into the sensory room. She said, as she escorted Resident #56 out of the room, the Resident had his/her hand on his/her left cheek and said it hurt. Activity Assistant #3 said Resident #56 should always be closely supervised if he/she is up, she said the Resident has a history of wandering, getting close in other resident's personal spaces. Activity Assistant #3 said there is not always enough staff to help supervise residents during activities. She said it would be beneficial to have more than one staff during activities with residents with a behavior history. Activity Assistant #3 said the incident between Resident # 23 and #56 was physical abuse because Resident #23 inflicted physical pain on Resident #56. During a telephone interview on 1/9/25 at 9:06 A.M., Nurse #12 said on 12/6/24, Resident #23 was watching television in the Activity room. She said Resident #56 was in the same Activity room, wandering around the room. She said Resident #56 has a history of getting close to other residents, she said he/she got close to Resident #23's face, he/she did not like it, he/she pinched Resident #56's lower left cheek. Nurse #12 said the Activity Assistant brought Resident #56 to her after the incident. She said the Resident was covering the left cheek with his/her hand, saying it hurt. She said the cheek was red for several hours. She said staff should be aware when Resident #56 is up and about, they should closely supervise him/her and be ready to separate him/her when he/she enters other residents' personal spaces. Nurse #12 said the incident between Resident #56 and #23 was physical abuse because it was a physical altercation between two residents. During an interview on 1/9/25 at 9:47 A.M., Unit Manager #1 said she was not in the facility when the incident happened between Resident #56 and #23. She reviewed the progress notes and said when incidents such as these happen, the expectation is for staff to redirect the residents involved, assess for injuries, start an investigation and notify the Director of Nurses immediately. She said abuse can be defined as the willful inflicting of harm on another person, she said abuse can happen between residents or staff and residents. She said the incident that happened between Resident #23 and #56 was physical abuse. During an interview on 1/9/25 at 10:14 A.M., the Director of Nurses said on 12/6/24, Resident #56 and #23 were both in an unsupervised common area, she said after the incident occurred, the Residents were redirected to a supervised common area. She said based on Resident #56's behavior history of wandering and getting in other resident's personal spaces, she expects staff to supervise him/her on the unit. The DON said an event report was completed after the incident occurred. She said it was determined that Resident #23's intentions were not to harm Resident #56 even though he/she retaliated aggressively by pinching Resident #56 causing pain on his/her left cheek. The DON said after using the [NAME] navigation tool, (This tool was built to help Massachusetts health care providers navigate key state and federal requirements for reporting adverse and other events that affect patient safety). As a facility, they determined that the incident was not abusive. During an interview on 1/9/25 at 12:14 P.M., both the DON and the Administrator defined abuse as causing physical, mental and emotional harm to another person. They both defined physical abuse as striking or unwanted contact between residents, or residents and staff with purposeful infliction with intent to harm.

Based on observations, interviews and record review, the facility failed to maintain privacy and confidentiality of personal and medical records on one out of three resident units. Findings include: A review of the facility policy titled 'Patient Confidentiality' revised November 2024 indicated the following: -Patient confidentiality is keeping information about a patient's healthcare private. -Protect all records-keep all resident information covered. Don't leave it where unauthorized people can see it. On 1/6/25 at 8:02 A.M., the surveyor observed Nurse #10 at the medication cart. Nurse #10 walked away from the medication cart down the hall, left the computer screen unlocked revealing residents' medical and private information. Nurse #10 returned to the medication cart, did not lock the computer screen, walked away from the medication cart again, and walked down the hall. On 1/7/25 at 12:50 P.M., the surveyor observed Nurse # 11 at the medication cart. Nurse #11 walked away from the medication cart to the medication room leaving the computer screen unlocked revealing residents' medical and private information. Nurse #11 returned to the medication cart, left the computer screen unlocked, went into a resident's room, then walked back to the medication room. During an interview on 1/7/25 at 1:43 P.M., Nurse #11 said she is supposed to lock the computer screen to maintain privacy of the medical record when she walks away from the medication cart. During an interview on 1/7/25 at 2:58 P.M., Nurse #10 said the medication cart computer should always be locked to protect resident medical records if the Nurse is not at the medication cart. During an interview on 1/9/25 at 1:04 P.M., the Director of Nurses said she expects the Nurses working on the medication carts to lock their computer screen prior to walking away from the medication cart. She said this ensures that the residents' medical information is kept private and confidential.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#94), out of a total sample of 29 residents. Findings include: Review of the facility policy titled Advanced Directives, dated 11/5/24, indicated The Advanced Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in resident. The Facility will implement the instructions outlined in the Advanced Directive. Resident #94 was admitted to the facility in February 2024 with diagnoses that included dementia, adult failure to thrive, and anxiety. Review of Resident #94's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a zero out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. The MDS further indicated the Resident's code status is DNR (Do Not Resuscitate) and DNI (Do Not Intubate). Review of Resident #94's physician order, dated 5/21/24, indicated FULL CODE, Do not Intubate and Ventilate, No artifial [sic] Nutrition. Review of Resident #94's MOLST (Medical Orders for Life Sustaining Treatment), dated 8/29/24, indicated the Resident is a DNR, DNI, no dialysis, no artificial nutrition. During an interview on 1/8/25 at 1:43 P.M., Nurse #3 said the MOLST should match the physician order so the nurses are clear on what the code status is for that Resident. Nurse #3 reviewed Resident #94's MOLST with the surveyor and said it does not match the physician order. During an interview on 1/8/25 at 1:49 P.M., the Director of Nurses (DON) said the MOLST should match the physician order.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive Plan of Care for Activities of Daily Living (ADLs) indicated he/she required assistance of one staff member when eating, the Facility failed to ensure staff implemented and followed interventions identified in his/her comprehensive plan of care related to staff assistance during meals. On 5/03/23, Resident #1 was left alone and without staff assistance in his/her room with his/her breakfast meal, he/she choked on food, became unresponsive, and required the Heimlich Maneuver. Resident #1 was transferred to the Hospital Emergency Department via 911, was diagnosed with acute hypoxic respiratory failure, aspiration pneumonia, sepsis, and dysphagia (condition with difficulty in swallowing food or liquid, may interfere in a person's ability to eat and drink), and was admitted to the Hospital for five days, where he/she required treatment with intravenous (I.V.) antibiotics. Findings include: The Facility's Policy, titled Person-Centered Care Plan, dated 10/24/22, indicated: -The interdisciplinary team, in conjunction with the patient and/or representative, would establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. -The Care Plan would be customized to each resident's preferences and needs. -The Care Plan would be communicated to appropriate staff. The Facility Policy, titled Activities of Daily Living (ADLs), indicated residents would be assessed to identify their status in all areas of ADLs and inability to perform ADLs, and a resident who was unable to carry out ADLs would receive the necessary level of ADL assistance. The Facility's Policy, titled Meal Services, dated 08/31/21, indicated: -Meal service included the delivery of a safe and comfortable environment. -When meals were served in a resident's room and the resident required assistance, staff would not deliver the tray until assistance could be provided and would sit next to the resident while assisting to eat. -Staff would provide assistance during meal services to meet resident needs, which included providing cueing, prompting, or assistance, when applicable. Resident #1 was admitted to the Facility in February 2023, diagnoses included dysphagia (difficulty swallowing), and dementia. The Activities of Daily Living Care Plan, dated 02/22/23, indicated Resident #1 required nursing staff to provide assist of one for eating, or constant supervision at times when he/she was participating with meals and the eating process. Review of Resident #1's Minimum Data Set (MDS, Medicare-required five day Skilled Nursing Facility Prospective Payment System (PPS) assessment), dated 03/07/23, indicated Resident #1 required extensive physical assistance of one staff member with eating. Resident #1's most current Care Kardex Report, for May 2023, indicated staff were to provide Resident #1 with assist of one for eating. The Nurse Progress Note, dated 05/03/23, indicated Resident #1 was choking while having breakfast, Code Blue was initiated, nursing staff performed the Heimlich Maneuver, and his/her mouth was cleared. The Nurse Progress Note indicated Resident #1 became unresponsive, was bluish in color, and his/her oxygen saturation level (SaO2, a measure of the level of oxygen saturation of circulating blood, normal range is between 95% to 100%) dropped to 70% on room air. The Nurse Progress Note indicated Resident #1 was transferred to the Hospital Emergency Department via 911. The Hospital History and Physical (H&P) Note, dated 05/03/23, indicated Resident #1 had choked on breakfast at his/her Facility, became unresponsive, and was transferred to the Hospital Emergency Department where he/she was diagnosed with aspiration pneumonia. The H&P Note indicated Resident #1's oxygen saturation had dropped to the low 50's, and he/she had remained unresponsive when Emergency Medical Services arrived, required emergency breaths via bag valve mask (hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). The H&P Note indicated Resident #1 was admitted to the Hospital with diagnoses of acute hypoxic respiratory failure, aspiration pneumonia, sepsis, and dysphagia, and required I.V. antibiotics. During interview on 05/17/23 at 9:32 A.M., Certified Nurse Aide (CNA) #2 said she was assigned to care for Resident #1 on 05/03/23, and said she was familiar with him/her. However, CNA #2 also said she did not know Resident #1 required one staff member to assist with meals. CNA #2 and said staff would set him/her up to eat in his/her room and would then do rounds in the hallway, and check in on him/her, reminding Resident #1 to eat. CNA #2 said Resident #1 would occasionally cough while eating. During interview on 05/17/23 at 7:59 A.M., Certified Nurse Aide (CNA) #1 said that on 05/03/23 at 8:30 A.M., during the breakfast meal, she was walking by Resident #1's room and saw him/her with his/her breakfast tray on a bedside table in front of him/her, sitting on the edge of his/her bed, trying to stand up, waving his/her arms around in the air with a panicked expression on his/her face, was trying to swallow and appeared to be choking. CNA #1 said she yelled for help, and Nurse #1 and Nurse #2 responded. CNA #1 said there were no staff members in Resident #1's room and said Resident #1 could not be seen while he/she was eating from the Nurses' station. During interview on 05/17/23 at 9:14 A.M., Nurse #1 said that on 05/03/23 at 8:30 A.M., she heard CNA #1 call out that Resident #1 was choking. Nurse #1 said when she went to Resident #1's room he/she was coughing and choking, and eventually stopped coughing. Nurse #1 said she performed the Heimlich Maneuver and was able to clear a large amount of scrambled eggs from Resident #1's mouth, then Resident #1 became unresponsive, a Code Blue was called, and he/she was transferred to the Hospital Emergency Department via 911. During interview on 05/17/23 at 10:31 A.M., Nurse #2 said that on 05/03/23 he was Resident #1's assigned nurse. Nurse #2 said that Resident #1 required assistance with meals and normally ate in the dining room on the unit but had refused to go to the dining room for breakfast that day, so he let him/her stay in bed and was going to reapproach him/her later. Nurse #2 said that at 8:30 A.M., he heard CNA #1 yell for help, said when he got the Resident #1's room, Nurse #1 was already there and Resident #1 was coughing and choking, and then stopped breathing. Nurse #2 said he and Nurse #1 both performed the Heimlich Maneuver, swiped Resident #1's mouth, and cleared a large amount of what appeared to be scrambled eggs from his/her mouth. Nurse #2 said Resident #1 was unresponsive, and his/her SaO2 dropped into the low 70%s. Nurse #2 said staff applied oxygen via a nonrebreather mask (used to deliver high oxygen flow) to Resident #1 and his/her Sa02 went back up to the 80%s. Nurse #2 said Resident #1 was then transferred to the Hospital Emergency Department via 911. During interviews throughout the survey, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, Nurse #1, Nurse #2, and Nurse #3 all said staff could access each resident's Care Plan electronically via the Facility's tablet. Throughout the course of this survey, the surveyor was unable to identify who brought Resident #1's breakfast tray to his/her room, and left him/her alone with the meal. During interview on 05/17/23, the Director of Nurses (DON) said Resident #1 had a history of dysphagia, his/her Plan of Care indicated he/she required assistance of one staff member for eating and should not have been left alone with his/her meal, as he/she was at risk for choking. On 05/17/23, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 05/08/23, The Hospital Discharge Summary indicated Resident #1 returned to the Facility, he/she was referred to Speech Therapy, and his/her diet texture was changed to puree with nectar thick liquids. B) 05/08/23, the Quality Assurance Performance Improvement Ad-Hoc meeting minutes indicated the Facility's Interdisciplinary Team met to review the incident and develop a plan of correction. C) 05/08/23, Resident #1's Care Plan was reviewed, and his/her interventions for eating remains as physical assistance of one staff member. D) 05/08/23, the Meal Assistance Audit Tool indicated all residents were audited for Care Plan interventions related to eating. E) 05/08/23, The QAPI meeting minutes indicated the Management team will conduct random audits at a minimum of twice weekly, to ensure that residents that require any form of assistance with meals receive the correct assistance and in the right setting. F) 05/08/23, The audits will be reviewed and reported at the QAPI committee meeting for four months and evaluated as needed. G) 05/12/23, the In-Service sign in sheet indicated the Unit Managers educated nursing, rehabilitation, and activities staff that all meal trays must be checked by the Nurse, and all residents must be supervised or assisted as indicated on their Care Plans. H) The Director of Nurses is responsible for oversight and ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a known history of dysphagia and whose comprehensive plan of care indicated he/she required assistance of one staff member with eating, the Facility failed to ensure he/she was provided with the necessary level of staff assistance while eating in an effort to maintain his/her safety and prevent an episode of choking. On 05/03/23, Resident #1 was left alone in his/her room with his/her breakfast meal. Resident #1 choked, became unresponsive, required the Heimlich Maneuver, was transferred to the Hospital Emergency Department via 911. Resident #1 was diagnosed with acute hypoxic respiratory failure, aspiration pneumonia, sepsis, and dysphagia (a condition with difficulty in swallowing food or liquid, may interfere in a person's ability to eat and drink), was admitted to the Hospital for five days and required treatment with intravenous (I.V.) antibiotics. Findings include: The Facility Policy, titled Accidents and Incidents, dated 10/24/22, indicated an incident was defined as any occurrence not consistent with the routine operation of the Facility or normal care of the resident. The Facility's Policy, titled Meal Services, dated 08/31/21, indicated: -Meal service included the delivery of a safe and comfortable environment. -When meals were served in a resident's room and the resident required assistance, staff would not deliver the tray until assistance could be provided and would sit next to the resident while assisting to eat. -Staff would provide assistance during meal services to meet resident needs, which included providing cueing, prompting, or assistance, when applicable. Resident #1 was admitted to the Facility in February 2023, diagnoses included dysphagia (difficulty swallowing), and dementia. The Activities of Daily Living Care Plan, dated 02/22/23, indicated Resident #1 required nursing staff to provide assist of one for eating, or constant supervision at times when he/she was participating with meals and the eating process. The Medicare-required five day Skilled Nursing Facility Prospective Payment System (PPS) assessment, dated 03/07/23, indicated Resident #1 required extensive physical assistance of one staff member for eating. Review of Resident #1's current Care Kardex Report, for May 2023, indicated staff were to provide Resident #1 with assist of one with eating. The Nurse Progress Note, dated 05/03/23, indicated Resident #1 was choking while having breakfast, Code Blue was initiated, nursing staff performed the Heimlich Maneuver, and his/her mouth was cleared. The Nurse Progress Note indicated Resident #1 became unresponsive, was bluish in color, and his/her oxygen saturation level (SaO2, a measure of the level of oxygen saturation of circulating blood, normal range is between 95% to 100%) dropped to 70% on room air. The Nurse Progress Note indicated Resident #1 was transferred to the Hospital Emergency Department via 911. The Hospital History and Physical (H&P) Note, dated 05/03/23, indicated Resident #1 was admitted to the Hospital Emergency Department indicated that Resident #1 had choked on breakfast became unresponsive, and was transferred to the Hospital Emergency Department where he/she was diagnosed with aspiration pneumonia. The (H&P) Note indicated Resident #1's oxygen saturation had dropped to the low 50's, and he/she remained unresponsive when Emergency Medical Services arrived, required emergency breaths via bag valve mask (hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). The (H&P) Note indicated Resident #1 was admitted to the Hospital with diagnoses of acute hypoxic respiratory failure, aspiration pneumonia, sepsis, and dysphagia, and required treatment with I.V. antibiotics. During interview on 05/17/23 at 9:32 A.M., Certified Nurse Aide (CNA) #2 said she was assigned to care for Resident #1 on 05/03/23, and said she was familiar with him/her. CNA #2 said she did not know Resident #1 required one staff member to assist with meals and said staff would set him/her up to eat in his/her room and would do rounds in the hallway, reminding Resident #1 to eat. CNA #2 said Resident #1 would occasionally cough while eating. During interview on 05/17/23 at 7:59 A.M., Certified Nurse Aide (CNA) #1 said that on 05/03/23 at 8:30 A.M., during the breakfast meal, she was walking by Resident #1's room and saw him/her with his/her breakfast tray on a bedside table in front of him/her, sitting on the edge of his/her bed. CNA #1 said Resident #1 was trying to stand up, waving his/her arms around in the air with a panicked expression on his/her face, that he/she was trying to swallow and appeared to be choking. CNA #1 said she yelled for help, and Nurse #1 and Nurse #2 responded. CNA #1 said there were no staff members in Resident #1's room while he/she was eating and said Resident #1 could not be seen from the Nurses' station. During interview on 05/17/23 at 9:14 A.M., Nurse #1 said that on 05/03/23 at 8:30 A.M., she heard CNA #1 call out that Resident #1 was choking. Nurse #1 said when she went to Resident #1's room he/she was coughing and choking, and eventually stopped coughing. Nurse #1 said she performed the Heimlich Maneuver and was able to clear a large amount of scrambled eggs from Resident #1's mouth, then Resident #1 became unresponsive, a Code Blue was called, and he/she was transferred to the Hospital Emergency Department via 911. During interview on 05/17/23 at 10:31 A.M., Nurse #2 said that on 05/03/23 he was Resident #1's assigned nurse. Nurse #2 said that Resident #1 required assistance with meals and normally ate in the dining room on the unit but had refused to go to the dining room for breakfast that day, so he let him/her stay in bed and was going to reapproach him/her later. Nurse #2 said that at 8:30 A.M., he heard CNA #1 yell for help, said when he got the Resident #1's room, Nurse #1 was already there and Resident #1 was coughing and choking, and stopped breathing. Nurse #2 said he and Nurse #1 both performed the Heimlich Maneuver, swiped Resident #1's mouth, and cleared a large amount of what appeared to be scrambled eggs from his/her mouth. Nurse #2 said Resident #1 was unresponsive, and his/her SaO2 dropped into the low 70%s. Nurse #2 said staff applied oxygen via a nonrebreather mask (used to deliver high oxygen flow) to Resident #1 and his/her Sa02 went back up to the 80%s. Nurse #2 said Resident #1 was then transferred to the Hospital Emergency Department via 911. During interviews throughout the survey, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, Nurse #1, Nurse #2, and Nurse #3 all said staff could access each resident's Care Plan electronically via the Facility's tablet. Throughout the course of this survey, the surveyor was unable to identify who brought Resident #1's breakfast tray to his/her room. During interview on 05/17/23, the Director of Nurses (DON) said Resident #1 had a history of dysphagia, his/her Plan of Care indicated he/she required assistance of one staff member for eating and should not have been left alone with his/her meal, as he/she was at risk for choking. On 05/17/23, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 05/08/23, The Hospital Discharge Summary indicated Resident #1 returned to the Facility, he/she was referred to Speech Therapy, and his/her diet texture was changed to puree with nectar thick liquids. B) 05/08/23, the Quality Assurance Performance Improvement Ad-Hoc meeting minutes indicated the Facility's Interdisciplinary Team met to review the incident and develop a plan of correction. C) 05/08/23, Resident #1's Care Plan was reviewed, and his/her interventions for eating remains as physical assistance of one staff member. D) 05/08/23, the Meal Assistance Audit Tool indicated all residents were audited for Care Plan interventions related to eating. E) 05/08/23, The QAPI meeting minutes indicated the Management team will conduct random audits at a minimum of twice weekly, to ensure that residents that require any form of assistance with meals receive the correct assistance and in the right setting. F) 05/08/23, The audits will be reviewed and reported at the QAPI committee meeting for four months and evaluated as needed. G) 05/12/23, the In-Service sign in sheet indicated the Unit Managers educated nursing, rehabilitation, and activities staff that all meal trays must be checked by the Nurse, and all residents must be supervised or assisted as indicated on their Care Plans. H) The Director of Nurses is responsible for oversight and ongoing compliance.

Based on observations, policy reviews, record reviews, and interviews the facility failed to: 1) maintain the safety of two Residents (#74 and #77) by preventing falls and elopements, out of a total 30 sampled residents, and 2) failed to secure sharp objects in the sharps container on one of three resident units. Findings include The facility policy titled Fall Management, dated as revised 6/15/22, indicated the following: * Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. * Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. The facility policy titled Elopement of Patient, dated as revised 10/24/22, indicated the following: * Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. *Once the patient is found review the details associated with the elopement and revise the patient's care plan as indicated to mitigate elopement risk. 1. For Resident #74, who requires continual supervision, the facility failed to provide the supervision, resulting in (a) an unwitnessed fall, requiring stitches and (b) two elopements from a secured unit. Resident #74 was admitted to the facility in September 2022 with diagnoses that included Dementia, history of falling and traumatic subarachnoid hemorrhage (SAH). The Resident resides on a locked unit at the facility and wears a wanderguard (a device to alert staff if he/she attempts to leave the unit). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/23/22, indicated Resident #74 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #74 had no behaviors, and required extensive assistance for ambulation. (a) During an observation on 12/13/22, between 8:10 A.M., and 9:45 A.M., the surveyor observed Resident #74 wandering alone up and down the unit's hallway, at times sitting alone in a staff break room, at the end of the hallway, next to the exit door. Staff were not providing assistance or supervision to the Resident while he/she was ambulating. Review of a Falls Report for Resident #74, dated 12/4/22, indicated the following: *Resident #74 was found on the floor in another resident's room and was bleeding profusely. The Resident was observed clutching his/her head with both hands while on the floor covered in blood. * Resident #74 had to be transported to the hospital and received 3 sutures to the laceration on his/her head in the emergency room . *A nurse statement indicated the fall was unwitnessed. Review of the most recent Licensed Nursing Summary prior to the fall, dated 11/22/22, indicated Resident #74 required continual supervision while ambulating. Review of Resident #74's Activities of Daily Living (ADL) care plan, last revised 11/22/22, indicated the following intervention: *Provide CS (continual supervision)/assist with ambulation. Review of Resident #74's kardex (instructions for staff on resident specific needs) indicated staff needed to provide continual supervision/assist with ambulation. Review of Resident #74's medical record failed to indicate the Resident was receiving continual supervision while ambulating on 12/4/22, when he/she was incidentally found in a peers room, on the floor, bleeding profusely and required sutures. During an interview on 12/14/22, at 12:22 P.M., Nurse #1 and Nurse #2 said Resident #74 wanders all the time, and they do their best to supervise him/her, but that it was not possible to do that at all times. During an interview with on 12/15/22, at 10:31 A.M., Certified Nursing Assistant (CNA) #2 said she regularly works with Resident #74 and that it is not possible to supervise him/her all the time when he/she was ambulating. During an interview on 12/15/22, at 10:49 A.M., Unit Manager #2 said the staff do their best to keep an eye on Resident #74, but that he/she had fallen while unsupervised. Unit Manager #2 said Resident #74 was care planned to receive continual supervision and assist with ambulation and could not say why Resident #74 was not being supervised at the time of the fall. During an interview on 12/15/22, at 11:44 A.M., the Director of Nursing (DON) said Resident #74 needs continual supervision and wasn't getting it when he/she fell and was injured requiring sutures. (b) During an observation and interview on 12/14/22, at 7:44 A.M., Nurse Unit Manager (#2) entered the unit from the elevator with Resident #74, as she loudly announced to the unit staff everyone stop what you are doing. Nurse Unit Manager #2 then saw the surveyor, stopped speaking and walked down the hallway with Resident #74. The surveyor spoke to Nurse Unit Manager #2 and inquired if Resident #74 eloped off the unit. Nurse Unit Manager #2 responded yes and said she found Resident #74 downstairs in another part of the facility and she did not know how he/she got off the secured unit. During an observation on 12/14/22, at 7:57 A.M.,13 minutes after eloping off the floor, Resident #74 was observed by the surveyor seated in a staff break room, unsupervised, at the end of the corridor, beside the exit door. Staff were observed on the unit, providing care to other residents. The surveyor continued to make the following observation: * At 8:04 A.M., Resident #74 was observed standing and hovering by an exit door, at far end of the hall, alone and unsupervised. Review of the nursing progress notes, dated 11/4/22, indicated Resident #74 had a previous elopement off the floor and had been found on a different nursing unit. Review of Resident #74's care plan, last revised on 11/8/22, indicated Resident #74 is at risk for elopement, wanders on unit, wanders into others' rooms, rummages, related to Cognitive Loss/Dementia. Review of the elopement assessment, dated 9/19/22, indicated the following: * Resident #74 had a history of actual elopement or attempted elopement. Review of the elopement assessment, dated 12/1/22, indicated the following: * Resident #74 has exit seeking behavior and hovers near exits. Review of the unit's Elopement book indicated Resident #74's name was on a list of residents on the unit at risk for elopement. The book failed to have a picture identification sheet for Resident #74, although all other residents on the list did. Pictures are in the elopement book to provide staff who are not familiar with the residents, such as agency staff that work at the facility, with a visual cue of high risk residents. As well, if a resident elopes, it provides those staff with a photo identifier when searching for the resident. During an interview on 12/14/22, at 12:22 P.M., Nurse #1 and Nurse #2 said Resident #74 wanders all the time, and they do their best to supervise him/her, but that it was not possible to do that at all times. Nurse #1 and Nurse #2 said all residents who wear wanderguards have their picture kept in the elopement book. Nurse #1 and Nurse #2 said they were both agency staff and they, as well as other staff, use the pictures in the elopement book to identify residents who they may not be familiar with. Nurse #2 went through the elopement book and said that Resident #74's photo was not in the book, but should be. During an interview on 12/15/22, at 10:31 A.M., with Certified Nursing Assistant (CNA) #2 she said she regularly works with Resident #74 and he/she wanders all over and pushes on the exit doors, we try to watch him/her, but yesterday he/she escaped when we were in the patient rooms giving care. CNA #2 added that it is impossible to supervise Resident #74 all the time when he/she was ambulating. During an interview on 12/15/22, at 10:49 A.M., Unit Manager #2 said the staff do their best to keep an eye on Resident #74, but that he/she has eloped off the unit. Unit Manager #2 could not say why Resident #74 was not being supervised at the times of elopement, as he/she was an elopement risk and was care planned to receive continual supervision and assist with ambulation. During an interview on 12/15/22, at 11:44 A.M., the Director of Nursing (DON) said Resident #74 requires continual supervision and was not getting it when he/she eloped off the unit both times. The DON said Resident #74's picture should be in the elopement book so staff, such as the agency staff the facility utilizes, could identify him/her if he/she was missing. 45763 2. For Resident #77, who requires physical assistance with toileting, the facility failed to provide assistance or supervision at the time of a fall. Resident #77 was admitted to the facility in May 2018 with diagnoses including Dementia, difficulty walking, need for assistance with personal care, and history of falling. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #77 scored an 11 out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Resident #77 requires extensive assistance from one staff when toileting, transferring and walking. Review of Resident #77's care plan for activities of daily living indicated that the Resident requires the assistance of 1 staff with toileting. Review of the falls report for Resident #77, dated 7/15/22, indicated that the Resident had experienced a fall while toileting independently. Review of the progress note dated 7/15/22, indicated that Resident #77 was observed on the floor, Resident 77 had stated that he/she lost balance while trying to toilet him/her self. Review of the certified nursing assistant (CNA) eyewitness report, dated 7/15/22, indicated that the CNA was in Resident #77's room making his/her roommate's bed at the time of the incident while the Resident was toileting. The CNA was not assisting or supervising the resident at the time of the fall, and the sound of the fall had alerted her to the occurrence. During an interview on 12/15/22, at 12:40 P.M., the Director of Nurses (DON) said that the incident report indicates that Resident #77 was in the bathroom alone while the Certified Nursing Assistant (CNA) was in the Resident's room. The DON said that the CNA should have kept eyes on the Resident, and if she had done so the fall may have been prevented. 43846 Review of the facility's policy, titled, Needle Handling and Sharps Injury Prevention, revised 10/15/19, indicated the facility will use specific safety devices with engineering controls designed to minimize worker exposure to blood or other potentially infectious materials through needlestick injuries in accordance with Occupational Safety and Health Administration (OSHA) Standards. On 12/14/22 at 12:21 P.M. the surveyor observed a medication cart sharps container open and unlocked next to a seated resident. Upon further inspection the surveyor observed there was not a lock in the hole where a lock would normally be on the securement box of the sharps container. During an interview on 12/14/22 at 12:21 P.M., Nurse #4 acknowledged that the sharps container was not locked and said it should be secured for safety. Nurse #4 said the whole lock is gone so there is no way to actually lock it. During an interview on 12/14/22 at 12:37 P.M., Maintenance Director #1 said he does not inspect the medication carts regularly unless staff tells him there is an issue. During an interview on 12/14/22 at 2:41 P.M., The Director of Nursing (DON) said the expectation is that the nurse who is on the medication cart would inspect their medication cart as they start their shift. The Director of Nursing said the maintenance department is responsible to empty and change out the sharps containers as needed and said they should have noticed there was not an actual lock where the lock should be on the securement box for the sharps container.

Based on observation, record review and interview, the facility failed to 1.) provide adequate supervision per the Resident's plan of care related to falls, resulting in a fall with injury for 1 Resident (#67) and 2.) failed to follow a Resident fall plan of care for 1 Resident (#4) out of a total of 23 sampled residents. Findings include: 1.) For Resident #67, the facility failed to provide adequate supervision per his/her plan of care resulting in a fall with injury. Resident #67 was admitted to the facility in November 2018 with diagnoses including Alzheimer's disease, anxiety and abnormalities of gait and mobility. Review of his/her most recent Minimum Data Set Assessment, dated 5/26/21, indicated that Resident #67 is severely cognitively impaired and requires assistance with bathing, dressing, transfers and supervision with ambulating. Additional review of Resident #67's MDS indicated that he/she is unsteady during transfers and walking, but is able to steady himself/herself with staff assistance. On 7/14/21 at 9:12 A.M., the surveyor observed Resident #67 attempting to get out of bed unassisted. Review of Resident #67's Quarterly Nursing Summary dated 5/26/21 indicated he/she is at risk for falls. Review of the facility's Fall Management policy, revised 6/1/21 indicated the following: Policy: Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Review of Resident #67's care plans indicated the following: Focus: Resident is at risk for falls. (11/6/18) Interventions: Provide verbal cues to resident when ambulating for poor safety awareness in tight surroundings. (12/12/19) Re-orient Resident to his/her room as he/she wanders into other resident's space. (5/30/20) Re-direct Resident out of other resident's rooms and back into a higher visual area with more supervision when he/she is wandering. (6/11/20) Focus: Resident is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, transfer, locomotion and tilting related to Alzheimer's muscle weakness and anxiety. (12/28/20) Intervention: 1 assist for ambulation due to increased confusion in evening time, unsteady upon rising (revised 3/9/21) Focus: Resident has potential to exhibit physical behaviors (revised 9/22/20). Interventions: Attempt to monitor resident as he/she is walking by other residents to divert him/her from touching their belongings (12/5/19) Divert Resident by assisting to other area/activity (11/10/18) Observe Resident when he/she enters room for taking items that are not appropriate (10/28/19) When Resident is restless ask him/her to sit next to you. (10/21/19) Focus: Resident has potential for little or no activity involvement. (1/15/20) Intervention: Encourage Resident participation in activity preferences. Walks with assist with staff only. (revised 6/7/21) Review of Resident #67's fall incident report dated 6/21/21 indicated that on 6/20/21 at 8:30 A.M., Resident #67 had wandered into another residents room. Resident #67 fell and sustained a [CONDITION(S)] requiring him/her to be sent to the hospital and receive 2 staples to his/her wound. During an interview with Nurse #2 on 7/15/21 at 12:16 P.M. she said that on 6/20/20 Resident #67 was wandering around the unit and she kept asking Resident #67 to sit down. Nurse #2 said that the meal truck arrived and she went to check the trays and the Certified Nurses Aides (CNAs) were somewhere else. Nurse #2 said that when she was checking the trays, Resident #67 wandered into another resident's room and the CNA's heard the fall. Nurse #2 said that Resident #67 frequently wanders the unit and does not require assistance. Nurse #2 said that staff try to redirect him/her when they can. During an interview with the Therapeutic Activity Director and Nurse #4 on 7/16/21 at 8:03 A.M., they said that Resident #67 walks on the unit alone without supervision and without assistance. They said that staff usually keep Resident #67 within eye sight when they can but he/she does walk alone. 2. For Resident #4, the facility failed to implement fall care plan interventions. Resident #4 was admitted to the facility in 3/2021 with a diagnosis of acute [CONDITION(S)]. An admission Minimum Data Set assessment indicated Resident #4 scored a 3 out of possible 15 on the Brief Interview for Mental Status, which indicated severe cognitive impairment, needs extensive assistance with bed mobility, transfers, toileting and ambulation and has had 2 or more falls since admission to the facility. Review of Resident #4's record and facility incident reports indicated Resident #4 fell 8 times since admission. Review of Resident #4's care plan for falls indicated the following interventions: - Bed/mattress perimeter reminder (bed roll, scoop mattress, etc.), initiated 4/9/21. - Place fall mats on the floor next to the bed, initiated 4/2/21. On 7/15/21 at 10:10 A.M., Resident #4 was lying in his/her bed. There were no mats on the floor next to the bed and there was no perimeter mattress on the bed. On 7/19/21 at 10:30 A.M., Resident #4's bed was observed with Nurse #5. Nurse #5 confirmed the absence of the fall mats on the floor next to the bed and no perimeter mattress on the bed.

Based on observation, record review and interview, the facility failed to identify and address the development of a new contracture (a shortening/hardening of the joints leading to deformity) of 1 Resident (#13) and failed to create and implement a care plan related to an existing contracture for 1 Resident (#100) out of a total of 23 sampled residents. Findings include: 1. Resident #13 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's most recent Minimum Data Set Assessment, dated 4/14/21, indicated that he/she is severely cognitively impaired and requires assistance with dressing, eating and bathing. During an interview with Resident #13 on 7/14/21 at 8:46 A.M., the surveyor observed that Resident #13's right hand was contracted into a fist. Due to Resident #13's cognitive impairment, he/she was unable to say exactly how long his/her hand had been contracted, but said that it was not always like that and it had become worse over time. Additional review of Resident #13's MDS' dated 8/5/20, 10/28/21, 1/20/21, indicated that he/she had no upper body impairment. Resident #13's MDS dated [DATE] indicated that he/she does have upper extremity impairment. Review of Resident #13's monthly nursing summaries from August 2020 through through June 2021 failed to indicate that Resident #13 had any contractures. Review of Resident #13's Alteration in Comfort care plan, dated 12/5/19 was updated to include that he/she had stopped using his/her right hand and would not allow staff to perform passive range of motion on 1/29/21. Review of Resident #13's additional clinical care plans failed to include any care plan that identified that Resident #13 had impaired range of motion, had developed a contracture, methods or equipment used to treat the contracture, or interventions utilized to prevent the worsening of the contracture. Review of Resident #13's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #3 on 7/16/21 at 10:23 A.M., she said that when Resident #13 was first admitted to the facility, he/she did not have a hand contracture. Nurse #3 said that she was not sure when his/her hand became contracted. During an interview with former Unit Manager #4 on 7/16/21 11:46 A.M., she said that Resident #13 did not always have a hand contracture but could not recall when Resident #13's hand first became contracted. During an interview with Nurse Practitioner #1 on 7/16/21 12:10 P.M., she said that Resident #13 had a slow decline, and was not sure when he/she developed his/her hand contracture. Review of Resident #13's Occupational Therapy (OT) evaluations dated 11/16/19, 1/22/20, 5/15/20, and 7/23/20 failed to indicate Resident #13 had a right hand contracture or limited use of his/her right hand. Review of Resident #13's OT Evaluation dated 11/17/20 indicated the following: Resident with a history of dementia who was referred to OT by nursing due to an exacerbation of his/her right hand contracture. During an interview with OT #1 on 7/26/21 at 11:15 A.M., OT #1 said that when she first assessed Resident #13 it was in November 2020 to assess an existing contracture. OT #1 could not say when Resident #13 began showing signs of limited range of movements. OT #1 said that ideally, nursing would refer residents for rehab services when they first begin showing signs of contractures to prevent or slow contractures but that does not usually happen. OT #1 could not say why Resident #13's plan of care did not include his/her right hand contracture. 2. Resident #100 was admitted to the facility in July 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that he/she is severely cognitively impaired and requires assistance with bathing, dressing and transfers, and has upper and lower impairment on one side of his/her body. On 7/14/21 at 8:43 A.M. the surveyor observed Resident #100's left hand was contracted into a fist. Review of Resident #100's care plans failed to indicate that he/she had a contracture or any limited range of motion, a means to monitor and care for the contracture or equipment utilized for comfort for the contracture, or interventions to prevent the contracture from worsening. During an interview with Physical Therapist #1 on 7/16/21 at approximately 1:30 P.M., she said she was not aware that Resident #100 did not have a care plan related to his/her left hand contracture and limited range of motion.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the Facility related to the need for pain management and rehabilitative therapy following a surgical procedure, the Facility failed to ensure that Resident #1 was provided with adequate pain management, and that despite Resident #1's complaints of severe pain, he/she waited more than five hours for his/her physician ordered narcotic pain medication to be administered. Findings include: Review of the Facility Policy titled Pain Management, dated as revised 11/1/19, indicated the following; - Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission, or with a change in pain status, - Pain management would be consistent with professional standards of practice, the comprehensive person-centered care plan and the patient's goals and preferences, - Clinicians were to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat and evaluate pain. Review of Resident #1's Nurse Progress Note, dated 1/17/20 at 5:37 P.M., indicated Resident #1 was admitted to the Facility from the hospital after undergoing a decompressive lumbar laminectomy (surgery to relieve pressure on a nerve) with posterior lumbar interbody fusion at lumbar discs 4-5 (surgically binding bones together). The Note indicated Resident #1 had a prior surgical history of spinal stenosis (narrowing of spinal cord that puts pressure on a nerve, resulting in pain) and disc surgery. The Note indicated Resident #1 was admitted for pain management and rehabilitative therapy. Review of Resident #1's Admission Nursing Documentation assessment, dated 1/17/20, indicated that section titled Pain Evaluation, was left blank. Review of Resident #1's Nurse Progress Note, dated 1/17/20 at 10:37 P.M., indicated that Resident #1 reported her/his pain level was an eight out of 10 (pain scale of one to 10, one being no pain and 10 being worst pain) and said his/her pain was severe. Review of Resident #1's Medication Administration Record [REDACTED]. During an interview on 3/06/20 at 2:06 P.M., Resident #1 said she/he had two back surgeries in a span of two weeks to reduce chronic pain. Resident #1 said that her/his pain was manageable when he/she arrived at the facility around 5:30 P.M., but said as the evening wore on his/her pain worsened and said he/she was in severe pain. Resident #1 said that he/she was told that the [MEDICATION NAME] and [MEDICATION NAME] medications ordered by the physician to help manage his/her pain, were not available and said he/she was given Tylenol for the pain. Resident #1 said because he/she was in severe pain, the Tylenol did not help relieve the pain. Resident #1 said that he/she was told by nursing staff that the [MEDICATION NAME] and [MEDICATION NAME] were not going to be delivered from the pharmacy until sometime early in the morning. Resident #1 said that she/he was up all night, crying and writhing in pain. Resident #1 said that he/she asked staff for a hot pad or warming blanket to try to help with the pain and said he/she was told by staff they did not have anything like that. Resident #1 said that he/she was begging for pain medication and said he/she was in agony all night waiting for it. Resident #1 said that his/her pain level was a 10 out of 10, all night. During an interview on 2/27/19 at 9:51 A.M., Certified Nurse Aide (CNA) #1 said that she was assigned to help care for Resident #1 on the evening shift of 1/17/20, and into the 1/18/20 night shift. CNA #1 said that Resident #1 had put the call bell on three times and said he/she was in pain. CNA #1 said she reported Resident #1's complaints of pain to Nurse #1 each time. During an interview on 3/3/20 at 1:26 P.M., Nurse #1 said that when he conducted an initial admission assessment (electronically time stamped as being completed at 5:36 P.M.) Resident #1 said he/she had pain down his/her left leg, and said his/her pain was manageable at that time. Nurse #1 said that he expected Resident #1's [MEDICATION NAME] and [MEDICATION NAME] to be delivered during the 2:00 A.M. pharmacy delivery. During an interview on 2/27/20 at 1:50 P.M., the Director of Nursing (DON) said that when patients are transferred from the hospital, it takes the pharmacy anywhere from four to six hours to deliver medications ordered by the physician to the facility. The DON said that medications can be taken from the Omnicell system (automated medication dispensing system, a locked unit where medications, including narcotics are stored) from which only authorized nursing staff can access and obtain medications that are not readily available. The DON said there is an adequate supply of stock of medications in the Omnicell system to cover the wait period until the pharmacy can deliver medications. The DON said the Omnicell system may only be opened by authorized nurses. Nurse #1 said he was a per diem (per day, not regularly scheduled) nurse and said he did not have authorization to access the Omnicell system. Nurse #1 said the two pain medications ordered for Resident #1 were not delivered from the pharmacy until around 4:00 A.M., and said when he administered Resident #1 his/her pain medications, Resident #1 complained that he/she was in a great amount of pain. The DON said that per diem nursing staff do not have authorization to access the Omnicell system. The DON said that there were three staff nurses on the night shift on 1/17/20 that had authorization to access to the Omnicell system and said one of the nurses could have accessed the Omnicell for Nurse #1 and obtained Resident #1's pain medication. Review of Resident #1's MAR indicated [REDACTED].M., more than five hours after Resident #1 initially complained of severe pain. During an interview on 2/27/20 at 9:31 A.M., Nurse #2 said on 1/18/20 at the start of the day shift, Resident #1 asked for pain medication and said he administered [MEDICATION NAME] and [MEDICATION NAME] at 9:15 A.M. Nurse #2 said Resident #1 said that he/she was upset because he/she called for pain medication several times during the night but had not gotten any and said Resident #1 complained that his/her pain was not managed. During an interview on 2/27/20 at 9:06 A.M., the Social Worker said Resident #1 told her that he/she had been in pain all night and had finally gotten pain medication at 4:30 A.M. The Social Worker said Resident #1 requested to be transferred back to the hospital. Review of the Stock Medication List for the Facility's Omnicell system, indicated that [MEDICATION NAME] 5-325 mg tablet was a stock medication. Nursing staff could have obtained the [MEDICATION NAME] from the Omnicell and it could have been administered in a timely manner to help manage Resident #1's pain, without having to wait for the pharmacy delivery. Review of the Omnicell Inventory list indicated that [MEDICATION NAME] was not listed as a stock medication. During an interview on 3/03/20 at 4:44 P.M., the Unit Manager said there is always a nurse on duty with authorization to enter the Omnicell system and able to obtain medications. The Unit Manager said that per diem staff members need to ask one of the authorized nurses on duty to obtain medications from the Omnicell system, if needed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), the facility failed to ensure that nursing staff followed and implemented interventions in his/her Plan of Care related to Advance Directives (a documentation in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness), when on [DATE], at approximately 11:30 P.M. Resident #1 was found exhibiting signs and symptoms of a significant change in medical condition including abnormal breathing and he/she was not immediately assessed by nursing to ensure life saving measures where provided per his/her advance directives. Findings Include: Resident #1 was admitted to the facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code status. Review of Resident #1's Plan of Care for Advance Directives, updated [DATE], indicated he/she had a completed MOLST, and was a full code, staff to attempt resuscitation, intubate and ventilate use, non-invasive ventilation and transfer to hospital. The Facility's Incident Report, dated [DATE], indicated on [DATE], Resident #1 who was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), died at the Facility and nursing staff did not initiate CPR. The Facility Policy titled, Cardiac and/or Respiratory Arrest, dated [DATE], indicated: -Patient identification mechanisms and information about each patient's Do Not Resuscitation (DNR) status will be easily accessible to direct care nursing staff for all patients. -If there is no visual identification of DNR status or no DNR order on the patient's medical record: Cardio-Pulmonary Resuscitation (CPR)/Automated Electronic Device (AED) certified staff will initiate CPR/AED application, call 911 and notify the primary physician, designate an individual to record events on the CPR/AED Flow sheet, continue CPR until EMS arrive and notify the family/health care decision maker of the patient's status. -Patients found in a cardiopulmonary arrest (e.g. no apparent pulse, blood pressure, or respiration) staff will call for assistance, alert the licensed nurse and CPR/AED certified staff, and prepare the patient for CPR/AED while determining the presence of a DNR. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:40 A.M. on [DATE]. CNA #1 said on [DATE] at approximately 11:30 P.M, upon entering Resident #1's room, she observed Resident #1's eyes closed, could hear Resident #1 breathing heavily and said he/she did not respond when his/her name was called. CNA #1 said she immediately called for the nurse to come to Resident #1's room. CNA #1 said Nurse #1, Nurse #2 and Nurse #3 came to Resident #1's room to check on him/her. The Surveyor interviewed Nurse #3 at 3:35 P.M. on [DATE]. Nurse #3 said she was the one who checked Resident #1's medical record to see what his/her code status was. Nurse #3 said the MOLST form she reviewed indicated a code status of a DNR. Nurse #3 said she did not confirm if Resident #1's name was on the MOLST form she was reviewing. Nurse #3 said she informed the other nurses that Resident #1 was a DNR. Nurse #3 said she did not observe Resident #1's vital signs being assessed when she entered Resident #1's room. Nurse #3 said she visually observed that Resident #1 was breathing abnormally and said she felt Resident #1 was not getting the oxygen he/she needed. Nurse #3 said she asked Nurse #1 to apply a non-breather oxygen mask on Resident #1. Nurse #3 said she did not assess Resident #1's vital signs, did not begin CPR or call medical emergency services (911), because she believed he/she was a DNR. Nurse #3 said shortly after Resident #1's non-breather oxygen mask was applied Resident #1 was pronounced dead. Nurse #3 said, after Resident #1 died , she went back and reviewed Resident #1's chart to call the family, and said that is when she realized Resident #1's code status was a Full Code and not a DNR. Nurse #3 said staff did not perform CPR on Resident #1 after realizing he/she was a Full Code. The Surveyor interviewed Nurse #2 at 1:32 P.M. on [DATE]. Nurse #2 said on [DATE] upon entering Resident #1's room, Resident #1 was not arousable and said she heard gasping sounds coming from Resident #1. Nurse #2 said she visually assessed Resident #1's breathing, but did not perform any other assessments which would included checking Resident #1's carotid pulse, blood pressure, temperature, respirations and oxygen saturation level, because she had been told he/she was a DNR. Nurse #2 said when she returned to Resident #1's room, Resident #1 died a short time later. The Surveyor interviewed Nurse #1 at 4:57 P.M. on [DATE]. Nurse #1 said, on [DATE] near the end of 3:00 P.M. to 11:00 P.M. shift, CNA #1 called for help in Resident #1's room. Nurse #1 said when she entered Resident #1's room, he/she did not verbally respond when his/her name was called. Nurse #1 said Resident #1 was unresponsive with his/her eyes closed, mouth was opened, he/she had abnormal breathing, with gasping low breath sounds heard and he/she laying on his/her side in bed. Nurse #1 said she did not do a clinical assessment on Resident #1. Nurse #1 said she visually assessed Resident #1's breathing, but said she did not perform any other assessments, because she had been told Resident #1 was a DNR. Nurse #1 said it was approximately ,[DATE] minutes after Resident #1 died that it was discovered that Resident #1's status was a Full Code, and not a DNR, and said they did not attempt CPR at that time. The Surveyor interviewed the Director of Nursing (DON) at 11:06 A.M. on [DATE]. The DON said on [DATE] Resident #1 was a Full Code, said nursing staff did not perform a clinical assessment on Resident #1 and did not initiate CPR, when Resident #1 was found in room unresponsive staff. The DON said he would expect the nurses to perform a clinical assessment which would include Resident #1's carotid pulse, blood pressure, temperature, respirations and oxygen saturation level. The DON said Resident #1 was a Full Code, CPR would be expected to be initiated and medical emergency services (911) to be called. The DON said staff did not follow and implement interventions per Resident #1's Advance Directive plan of care and Resident #1 died . The Facility was found to be in past non-compliance on [DATE], the Facility provided the Surveyor with a plan of correction which addressed concerns as evidenced by: A) Resident #1 died in the Facility on [DATE]. B) On [DATE], licensed staff completed competencies related to CPR, Obvious Clinical Signs of irreversible death and Academy code training. Documentation indicated the educational objective was signs and symptoms of irreversible death, how to enter advanced directives into Point Click Care system, emergency response procedure, identify and follow resident Advanced Directives, [MEDICAL CONDITION] procedure, two nurses need to check code status and abuse and neglect policy. C) The Facility Action Plan indicated, for their plan implemented on [DATE], nurses will not be scheduled to work until education was completed the following topics; re-educated that a resident who is a Full Code - CPR must be initiated unless signs and symptoms of irreversible death are noted, re-educated that code status is communicated by physician's orders [REDACTED]. Documentation indicated all re-education was completed. D) On [DATE] the Facility reviewed the list of CPR trained licensed nurses, identify nurses that needed to be re-certified - train and review daily schedule to assure that at least one CPR trained nurse on site every shift. Documentation indicated all re-education and certification was completed. E) On [DATE] chart audits were initiated to assure code status is clearly noted in chart and was completed on [DATE]. The facility's plan is to continuing monitoring. F) The Facility provided the Surveyor with documentation, dated [DATE], that indicated Facility's Action Plan. Starting on [DATE] random mock codes were conducted at least weekly on each shift. The Facility provided in-service documentation, dated [DATE], [DATE], [DATE] and [DATE], indicated Code Blue initiated. Documentation indicated the educational objective was a mock code - unwitnessed arrest, CPR procedure and AED form education. The Facility's plan is to continuing monitoring. G) The Facility provided the Surveyor with an updated Cardiac and/or Respiratory Arrest Policy, dated revision on [DATE]. The Facility removed annual training for licensed nurses in the evaluation of the obvious clinical signs of irreversible death and currently indicates licensed nurses will be trained in the evaluation of the obvious clinical signs of irreversible death upon hire. H) The Facility provided the Surveyor with in-service documentation, dated [DATE] and [DATE], that indicated nurses were educated on nursing documentation and conducting a nursing assessment. I) The Facility conducted an emergent Quality Performance Improvement Committee (QAPI) on [DATE] to discuss Resident #1's incident on [DATE]. The Facility will continue to conduct QAPI meetings to monitor license staff compliance related to assure code status is clearly documented in resident charts, conducting mock codes and emergency medical response procedures. J) The QAPI Committee will continue to review findings monthly with additional measures implemented as needed. K. The Director of Nurses and/or designee is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled resident's (Resident #1), who was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), the facility failed to ensure Resident #1 was provided Cardiopulmonary Resuscitation (CPR), and that Emergency Medical Services (EMS) (911) were promptly notified of the need for emergent services, when on [DATE], Resident #1 who was having a life threatening medical emergency and required transfer to the Hospital Emergency Department, died . 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. The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, required the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order or signs of irreversible death. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated (YEAR), survival chances decline with every minute that passes by ,[DATE]% within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. Chain of survival includes calling 911, giving immediate and effective CPR (30 compressions and 2 breaths), defibrillating (if no shock advised, continue CPR for about 2 minutes which is approximately 5 cycles of 30 compressions and 2 breaths, until prompted by AED to allow rhythm check), and providing basic life support until advanced life support and delivering post-arrest care, to minimize brain damage. CPR should be provided while AED pads are applied and until the AED is ready to analyze the rhythm. The Facility Policy titled, Cardiac and/or Respiratory Arrest, dated [DATE], indicated the following: -Patient identification mechanisms and information about each patient's Do Not Resuscitate (DNR) status will be easily accessible to direct care nursing staff for all patients. -If there is no visual identification of DNR status or no DNR order on the patient's medical record: CPR/Automated Electronic Device (AED) certified staff will initiate CPR/AED application, call 911 and notify the primary physician, designate an individual to record events on the CPR/AED Flow sheet, continue CPR until EMS arrive and notify the family/health care decision maker of the patient's status. -Patients found in a cardiopulmonary arrest (e.g. no apparent pulse, blood pressure, or respiration) staff will call for assistance, alert the licensed nurse and CPR/automated external defibrillator (AED) certified staff, and prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR). -If there is no visual identification of DNR status or no DNR order on the patient's medical record: CPR/AED certified staff will initiate CPR/AED application, call 911 and notify the primary physician, designate an individual to record events on the CPR/AED Flow sheet, continue CPR until EMS arrive and notify the family/health care decision maker of the patient's status. -Patients found in a cardiopulmonary arrest (e.g. no apparent pulse, blood pressure, or respiration) staff will call for assistance, alert the licensed nurse and CPR/AED certified staff, and prepare the patient for CPR/AED while determining the presence of a DNR. Resident #1 was admitted to the facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident's #1's Care Plan, dated [DATE], indicated Advance Directive (A legal documentation in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness) as a Full Code. Review of Resident #1's medical record indicated his/her advanced directives included a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, dated [DATE], which indicated Resident #1 was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing). Resident #1's Care Plan Evaluation, updated [DATE], indicated his/her Advanced Directives included a completed MOLST form, which indicated he/she was a Full Code, and for staff to attempt Resuscitation, intubate and ventilate use, non-invasive ventilation and transfer to hospital. The Surveyor interviewed Nurse #3 at 3:35 P.M. on [DATE]. Nurse #3 said on [DATE] when she reviewed Resident #1's medical chart she read Resident #1's code status as a DNR. Nurse #3 said upon entering Resident #1's room he/she had abnormal breathing, CPR was not initiated and medical emergency services (911) were not called. Nurse #3 said it was not until later after Resident #1 died , that it was identified Resident #1's status was a Full Code. The Surveyor interviewed Nurse #2 at 1:32 P.M. on [DATE]. Nurse #2 said on [DATE] upon entering Resident #1's room he/she was unable to be aroused, CPR was not initiated and medical emergency services (911) was not called. Nurse #2 said her understanding was that Resident #1 code status was a DNR, and said she was unaware he/she was a Full Code, until after he/she died . The Surveyor interviewed Nurse #1 at 4:57 P.M. on [DATE]. Nurse #1 said on [DATE] upon entering Resident #1's room he/she had abnormal breathing, CPR was not initiated and medical emergency services (911) was not called. Nurse #1 said her understanding was Resident #1's code status was DNR, and said she unaware Resident #1 was a Full Code until after he/she died . The Surveyor interviewed Director of Nurses (DON) at 11:06 A.M. on [DATE]. The DON said on [DATE] Resident #1 was found to be having difficulty with breathing, nursing staff did not initiate CPR, medical emergency services (911) were not called and Resident #1 died . The DON said staff were unaware Resident #1 was a Full Code and staff working that night identified Resident #1 has a DNR, which was incorrect. The Surveyor interviewed Nurse Practitioner at 3:29 P.M. on [DATE]. The Nurse Practitioner said on [DATE] she reviewed Resident #1's Code status with Facility staff and with Resident #1's Health Care Proxy. The Nurse Practitioner said Resident #1 was a Full Code status and she would expected nurses to perform a clinical assessment on Resident #1 which would include the following, listen to Resident #1's breathing, listen to lung sounds, assess heart rate, apply oxygen and to confirm the medical code status of Resident #1. The Nurse Practitioner said if Resident #1 was not breathing it would be expected of staff to initiate CPR and call medical emergency services. The Nurse Practitioner said CPR was not initiated, emergency services (911) were not called and Resident #1 died . The Facility was found to be in past non-compliance on [DATE], the Facility provided the Surveyor with a plan of correction which addressed concerns as evidenced by: A) Resident #1 died in the Facility on [DATE]. B) On [DATE], licensed staff completed competencies related to CPR, Obvious Clinical Signs of irreversible death and Academy code training. Documentation indicated the educational objective was signs and symptoms of irreversible death, how to enter advanced directives into Point Click Care system, emergency response procedure, identify and follow resident Advanced Directives, [MEDICAL CONDITION] procedure, two nurses need to check code status and abuse and neglect policy. C) The Facility Action Plan indicated, for their plan implemented on [DATE], nurses will not be scheduled to work until education was completed the following topics; re-educated that a resident who is a Full Code - CPR must be initiated unless signs and symptoms of irreversible death are noted, re-educated that code status is communicated by physician's orders [REDACTED]. Documentation indicated all re-education was completed. D) On [DATE] the Facility reviewed the list of CPR trained licensed nurses, identify nurses that needed to be re-certified - train and review daily schedule to assure that at least one CPR trained nurse on site every shift. Documentation indicated all re-education and certification was completed. E) On [DATE] chart audits were initiated to assure code status is clearly noted in chart and was completed on [DATE]. The facility's plan is to continuing monitoring. F) The Facility provided the Surveyor with documentation, dated [DATE], that indicated Facility's Action Plan. Starting on [DATE] random mock codes were conducted at least weekly on each shift. The Facility provided in-service documentation, dated [DATE], [DATE], [DATE] and [DATE], indicated Code Blue initiated. Documentation indicated the educational objective was a mock code - unwitnessed arrest, CPR procedure and AED form education. The Facility's plan is to continuing monitoring. G) The Facility provided the Surveyor with an updated Cardiac and/or Respiratory Arrest Policy, dated revision on [DATE]. The Facility removed annual training for licensed nurses in the evaluation of the obvious clinical signs of irreversible death and currently indicates licensed nurses will be trained in the evaluation of the obvious clinical signs of irreversible death upon hire. H) The Facility provided the Surveyor with in-service documentation, dated [DATE] and [DATE], that indicated nurses were educated on nursing documentation and conducting a nursing assessment. I) The Facility conducted an emergent Quality Performance Improvement Committee (QAPI) on [DATE] to discuss Resident #1's incident on [DATE]. The Facility will continue to conduct QAPI meetings to monitor license staff compliance related to assure code status is clearly documented in resident charts, conducting mock codes and emergency medical response procedures. J) The QAPI Committee will continue to review findings monthly with additional measures implemented as needed. K. The Director of Nurses and/or designee is responsible for overall compliance.

Based on record review and staff interview, the facility failed to ensure that 2 of 13 sampled Residents ( #4 and #8) in a total sample of 25, who sustained falls, was provided adequate supervision and effective interventions to prevent further falls and injury. Findings include: 1. For Resident #8, the facility failed to develop effective interventions consistent with the resident's needs and abilities. Further, the facility failed to provide adequate supervision to prevent 7 avoidable falls, resulting in injury for 2 of the 7 falls within a 3 month period. The following information was gathered when the clinical record was reviewed on 3/18/13. Resident #8 was admitted to the facility in 7/2012. [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15, indicating mild cognitive impairment. The resident required assistance in most activities of daily living including toileting although the resident was continent of bowel and bladder and attended hemodialysis three times a week. The resident required supervision and set up for eating. The corresponding Falls care plan was developed on 7/30/2012. Problem: Resident is at risk for falls due to poor safety awareness, deconditioning, ESRD, elevated phosphorus levels, poor carry-over and poor balance. Goal: Resident will have less than 3 falls within 90 days. Interventions: * PT treatment as ordered. * Provide verbal cues for proper pacing and energy conservation techniques. * Place call light within reach at all times. (There is documentation throughout each falls investigation that indicates that the resident is non-compliant with calling for assistance.) * Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. * When the resident is in bed, place all necessary personal items within reach. * Monitor for and assist toileting needs. * Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize. Further review on 3/18/13, identified a Behavior care plan developed on 8/21/12. It included and remained unchanged through the present, despite a sequence of falls and two with injury. Problem: Resident exhibits behavior, resists care or treatment, occasional non-compliance with fluid/diet restriction and safety measures. Goal: Resident will have less than 3 episodes per day of resisting care or non-compliance with diet/safety within 90 days. Interventions: * Approach calmly. * Familiarize with belongings and surroundings. * Listen to resident's needs and adjust plan as appropriate. * Listen to resident and try to calm. * Maintain consistent routine and caregivers. * Maintain a safe environment. * Psych evaluation as ordered. * Offer choices as able. * Praise cooperation and positive behaviors. * Provide 1-1 interactions and support as needed. * Remove resident from environment. Between 10/14/12 and 1/14/13, the resident fell 6 times within this three month period. Review of the incident reports and falls investigations on 3/18/13 included the following: * On 10/14/12 - Did not lock wheelchair and fell when sitting back down. Wheelchair education was provided. * On 10/29/12 - Attempting to self-transfer and fell . Staff documented that the resident "is non-compliant with safety awareness and calling for help" however, the care plan intervention was: The resident was reminded to ask for help. * On 11/21/12 - When watching TV in his/her room, the resident slid to floor between chair and dresser. Staff documented that the resident "is non-compliant with safety". Slip-resistant strip was placed on wheelchair seat and on floor and documented on the care plan. * On 12/13/12 - When standing up and holding walker with one hand, the walker fell and the resident fell . The resident sustained [REDACTED]. Staff documented the resident "is non-compliant with calling for assistance". No new care plan intervention was put in place. * On 12/18/12 - At 3:30 A. M., according to the Falls Investigation, the resident was noted to be drowsy in the wheelchair and was offered a recliner. There was no documentation indicating the resident's response. Nor was there documentation indicating why the resident was in the day room at 3:30 A.M. The resident fell asleep in the wheelchair while seated in the day room and fell forward out of the chair. This was witnessed by a nurse who was at the nurse's station. The nurse yelled to the resident but it was too late. A Certified Nurse aide documented in a witness statement dated 12/18/12, that the resident had been seated behind her in the TV room and fell asleep. The resident suddenly slipped out of the wheelchair to the floor. An x-ray was obtained on 12/18/12 which identified an impacted fracture of the base of the mid phalanx and a mild lateral displacement of the right 4th digit. Staff documented that the resident "was not always compliant with agreed upon interventions". Intervention added to the care plan: Staff to offer recliner when noted to be drowsy. (This was reported to DPH.) Unit Manager #2 was interviewed on 3/19/13 at 11:00 A.M., regarding the circumstances of the above fall and why the resident was in the day room sleeping in his/her wheelchair at 3:30 A.M. Unit Manager #2 said that the resident won't always sleep in his/her bed. * On 1/14/13 - Attempting to self-transfer and self-toilet and fell . Staff documented that the resident "was non-compliant with asking for help". Staff to encourage common areas and rehab. For 5 of the 6 above falls, staff documented that the resident was "non-compliant with safety awareness, calling for assistance and agreed upon interventions". Although there was a Falls care plan in place, it failed to address the resident's failure to comply with stated interventions and address alternative interventions for non-compliance. Likewise, there was a Behavior care plan in place that identified "occasional non-compliance with safety measures and diet restriction". However, the interventions in place did not address how the facility would deal with the resident's non-compliance, nor did the facility develop new behavior interventions since the original care plan was developed a month after admission and was not effective. By the 1/16/13 quarterly MDS the resident's mental status had declined to a Brief Interview for Mental Status (BIMS) score of 6 out of a possible score of 15, indicating severe cognitive impairment. This decline over the last 3 months made it increasingly unlikely for the resident to be relied on to follow through with safety measures such as consistently calling for assistance. Further review of the clinical record on 3/18/13, indicated that the resident's roommate reported to staff on 1/17/13, that the resident was on the floor again after trying to self- transfer from his/her bed. Observation of the resident on 3/18/13 at the noon meal revealed the resident seated in the day room with 2 bowls of cereal and a cup of coffee which were his preference according to staff.. On 3/19/13 at 10:30 A.M. and on 3/20/13 at 3:00 P.M., the resident was also observed in the day room sitting in a wheelchair appearing to be dosing. Two staff members were in and out of the room as were other residents. There was no observation or documentation that the resident was offered a recliner per care plan intervention above. On 3/20/13 at 2:00 P.M., Unit Manager #2 was interviewed regarding the multiple falls of this confused, elderly resident and his/her documented "non-compliance with safety measures and follow-through with requesting assistance". Unit Manager #2 said that she agreed that the interventions for behavior and non-compliance did not adequately address the needs of this resident. Further, she said that there will be more attention paid to the development of effective care plan interventions, in order to ensure the resident's safety and prevent falls and injury. The facility failed to develop effective interventions to address this resident's repeated failures to comply with safety measures due to inability or reluctance and failed to provide adequate supervision to keep this resident safe. 2. For Resident #4, the facility failed to ensure that adequate supervision and assistance was provided to keep this resident safe. The following information was gathered when the clinical record was reviewed on 3/18/13. Resident #4 was originally admitted to the facility in 10/2009 and readmitted in 8/2012. [DIAGNOSES REDACTED]. Review on 3/18/13, of nursing progress notes, incident reports and falls investigations, indicated that the resident had a history of [REDACTED]. The Falls care plan in place since 10/8/09 included the following intervention: "Encourage resident to spend time in dayroom in between meals, activities/therapy sessions." * On 5/7/12 at 11:15 A.M., per Fall Investigation, the resident was seated in a chair in the TV room. A thud was heard and the resident was "found" on his/her back next to the gerichair with a laceration on his/her forehead. The resident was sent to the ER with a laceration to his/her forehead and returned with 13 sutures. The care plan was adjusted to include: Psychiatric medication review, rehabilitation screen and pain assessment. The Long Term Care Fax Report dated 5/8/12, included that "the resident can be impulsive at times and has poor insight to his/her safety. Although the resident was brought to the TV room after A.M. care, his/her CNA left for break per witness statement, and staff reported that they heard a thud but did not witness the fall as it occurred so fast. The annual Minimum Data Set (MDS) of 6/6/12, identified the resident as having a Brief Interview for Mental Status (BIMS) score of 2 out of a possible score of 15, indicating severe cognitive impairment. The resident required total assistance in all activities of daily living and was unable to ambulate. When the care plan added updated interventions, they were documented at the end of each fall description. The resident continued to fall and was found in his/her room on the following days: *On 6/18/12 at 10:30 A. M, per Falls Investigation, when attempting to self-toilet, (The annual MDS of 6/6/12 scored transfer 3/3 and ambulation 8/8) the resident was heard calling , "Help." The resident was found sitting on his/her buttocks, stating, "Pick me up. I need to go to the bathroom." New care plan intervention: Staff encouraged to offer to toilet between 10:00 A.M. and 11:00 P.M. There was no toileting plan in place, nor was the resident appropriate for a toileting plan. * On 6/25/12 at 8:30 P.M., per Falls Investigation, the resident was heard to yell, "Help"from the bedroom and was found on the floor with head by the bathroom door. (The annual MDS of 6/6/12 continued to score transfer 3/3 and ambulation 8/8). Following the fall, the resident was brought close to the nurses' station for observation and neurological vital signs. The quarterly MDS of 2/20/13 continued to identify the resident as having severe cognitive impairment and requiring total care for all activities of daily living. The Falls care plan continued to include keeping the resident in a common area such as the dayroom which was initiated on 10/8/09. Once again the resident had a fall in the TV/dayroom: * On 2/23/13 at 10:30 A.M., per Falls Investigation, the resident attempted to ambulate in the dayroom from a seated position and fell to the floor on his/her left side. (The quarterly MDS of 2/20/13 scored the resident as 3/3 for transfer and 3/2 for ambulation.) There was no documentation in the investigation indicating whether there was staff in the room. Although the resident was to be kept in a common area for observation since 2009, the resident had 4 falls. On 2/23/13 the facility reassessed and determined that "after meals, the resident was to be brought out to the corridor near the nurse's desk, reclined in a Broda chair to enable the resident to rest due to becoming over-stimulated and anxious in the common area." The resident was observed on 3/18/13 at 12:30 P.M. being fed by a CNA. The resident had been sleeping in bed and was approached and the head of the bed was elevated so that the resident could be fed. The resident was very difficult to feed as he/she constantly screamed : "Put my head down." The resident would become increasingly agitated and was difficult to redirect and feed. The CNA stated at this time that, once the resident gets upset, it is difficult to get him/her to focus again. Unit Manager #2 stated during Interview on 3/20/13 at 2:00 P.M.,that staff have been trying to keep the resident in a common area only to recently discover that this intervention was not appropriate, as the resident becomes over-stimulated in this environment. We will be more attentive to the development of effective care plan interventions, in order to ensure the resident's safety and prevent falls and injury.