Every finding on record at Berkshire Rehabilitation & Skilled Care Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 01/24/26, several staff members witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a demeaning and derogatory manner, while redirecting him/her.Findings include: Review of the Facility's Resident Rights Policy, dated as revised July 2021, indicated that residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/27/26, indicated staff alleged that on 01/24/26 at 10:45 A.M., CNA #1 pushed Resident #1 and told him/her, You're nasty!Resident #1 was admitted to the Facility in March 2023, diagnoses included Parkinson's disease, schizophrenia and unsteadiness on feet. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/26, indicated Resident #1 was severely cognitively impaired with a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her Quarterly MDS, completed 01/04/26, indicated he/she had a history of wandering intrusively and being aggressive toward staff. The Care Plan interventions indicated Resident #1's wandering behavior should be addressed by attempting to redirect him/her and engaging him/her in a diversional activity. Further review of the Care Plan indicated staff should approach Resident #1 in a calm manner, divert his/her attention, and remove him/her from the situation to another location as needed. During a telephone interview on 05/27/26 at 10:11 A.M., Certified Nurse Aide (CNA) #4 (which also included a review of her Written Witness Statement, dated 01/30/26) said that she witnessed an altercation between Resident #1 and CNA #1 on 01/24/26. CNA #4 said that CNA #1 told Resident #1, You're gross, and used hand gestures indicating that he/she (Resident #1) should move away from her. During an in-person interview on 05/27/26 at 1:05 P.M., Certified Nurse Aide (CNA) #3 said that she witnessed an altercation between CNA #1 and Resident #1 at the nurses' station near the end of the evening shift on 01/24/26. CNA #3 said that Resident #1 wandered out of his/her room, approached the nurses' station and stood within CNA #1's personal space. CNA #3 said that CNA #1 held up her hand to Resident #1 and stated to him/her, Get out of here, you're gross!During a telephone interview on 05/26/26 at 3:25 P.M., Certified Nurse Aide (CNA) #2 said that on 01/24/26 around 10:30 P.M., Resident #1 approached CNA #1, at which time CNA #1 placed her hands on his/her chest in a manner to redirect him/her and stated to him/her go! and get your nastiness away from me!During a telephone interview on 05/27/26 at 9:00 A.M., Nurse #1 said that Resident #1 frequently stood too close to others and had difficulty understanding and maintaining appropriate personal boundaries. Nurse #1 said that on 01/24/26 around 10:30 P.M., Resident #1 was wandering near the nurses' station when CNA #1 stated to him/her to get your nasty away from me while putting her hand on his/her chest. Nurse #1 said Resident #1 did not appear to react to the contact or lose his/her balance; instead, he/she changed direction and walked away from the area. Nurse #1 further said that she advised CNA #1 that Resident #1 should have been redirected in a respectful and professional manner.Review of CNA #1's Written Witness Statement, dated 01/27/26, indicated [that on 1/24/26 during the evening shift] she was at the nurses' station when Resident #1 approached her and stood within her personal space. The Statement indicated that she (CNA #1) put her hand up and asked Resident #1 to move away in a polite manner. The Surveyor was unable to interview Certified Nurse Aide (CNA) #1 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During an interview on 05/27/26 at 4:00 P.M., the Director of Nurses (DON) said that the Facility's investigation determined that Certified Nurse Aide (CNA) #1 failed to treat Resident #1 with dignity and respect during her interaction with him/her on 01/24/26. The DON further said that CNA #1's employment was terminated on 02/04/26 as a result of the incident.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to Facility administration, when: 1). On 01/24/26, Nurse #1 witnessed an incident involving possible verbal and physical abuse between Certified Nurse Aide (CNA) #1 and Resident #1, did not immediately notify Facility administration. but left a note describing the event under the Nursing Supervisor's office door, where it was not discovered until 01/27/26, three days later. 2). On 4/28/26 around 3:45 P.M., although staff were aware that a physical altercation had occurred between Resident #2 and Resident #3, they did not immediately notify a supervisor, per Facility policy, but waited until 8:30 P.M. (almost five hours later) to report it. Findings include:1). Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated it was the policy of the Facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The Policy also indicated that the Facility would have written procedures that include reporting of alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames:-immediately but not later than two hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury or,-not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/27/26, indicated staff alleged that on 01/24/26 at 10:45 A.M., CNA #1 pushed Resident #1 and told him/her, You're nasty! Review of written communication (later identified as the note left under the Nursing Supervisor's door), signed and dated 01/24/26 at 10:45 P.M. by Nurse #1, indicated it reported an allegation that Certified Nurse Aide (CNA) #1 pushed Resident #1 and told him/her I don't want your nasty near me.During a telephone interview on 05/27/26 at 9:00 A.M., Nurse #1 said that on 01/24/26 around 10:30 P.M., Resident #1 was wandering near the nurses' station when CNA #1 made physical contact with Resident #1 and stated to him/her, get your nasty away from me. Nurse #1 said that she wrote a note detailing the incident and slid it under the Nursing Supervisor's office door on 01/24/26. Nurse #1 said that she should have reported the incident to Facility administration immediately by phone. During an interview on 05/27/26 at 4:00 P.M., the Director of Nurses (DON) said that she first became aware of the allegation of abuse involving CNA #1 and Resident #1 on 01/27/26, when the Nursing Supervisor found a note from Nurse #1 reporting the alleged incident. The DON further said the expectation was for all allegations of abuse to be reported to Facility administration immediately.2). Review of the Facility Policy titled Resident to Resident Altercation, dated April 2025, indicated that all staff are to report any suspected resident to resident altercations immediately to their supervisor. Review of the Report submitted by the Facility via HCFRS, dated 04/28/26 at 8:30 P.M., indicated that Resident #3 became angry with Resident #2 and punched him/her in the face, resulting in a nosebleed. Further review of the Report indicated that both Resident #2 and Resident #3 were sent to the Emergency Department (ED). Review of Resident #3's Nurse Progress Note, dated 04/28/26, indicated that around 3:45 P.M. Resident #3 was in the hallway getting assistance from staff when Resident #2 approached him/her, and he/she responded by punching Resident #2 in the face. The Note indicated that Resident #3 was sent to the ED to be evaluated. Review of Resident #2's Nurse Progress Note, dated 04/28/26, indicated that around 3:45 P.M., Resident #2 approached Resident #3 in the hallway and despite staff intervention, he/she was struck in the face by Resident #3, resulting in a nosebleed. The Note indicated that Resident # 2 was sent to the ED for evaluation. The DON said that on 04/28/26, around 8:30 P.M., she contacted the Facility about an unrelated matter. The DON said that during that conversation, the nurse informed her of an altercation that had occurred around 3:45 P.M., between Resident #3 and Resident #2. The DON said that Facility policy requires all allegations of abuse, including resident to resident altercations to be reported to Facility administration immediately.

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure that on 04/28/26, after being made aware of an allegation that Resident #3 punched Resident #2 in the nose, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a final investigation report was submitted to the Massachusetts Department of Public Health (DPH) within five days, as required.Findings include:Review of the Facility Policy titled Abuse, Neglect and Exploitation, dated as implemented February 2023, indicated the Administrator will follow-up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. The Policy indicated that once an investigation has been completed, the five-day follow-up should be reported to DPH via the electronic reporting platform. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/28/26, indicated that Resident #3 became angry with Resident #2 and punched him/her in the face, at 8:30 P.M., resulting in a nosebleed. The Report indicated the altercation was witnessed by Resident #4 who had reported observing Resident #2 push Resident #3, after which Resident #3 punched Resident #2 in the nose. Further review of the Report indicated that both Resident #2 and Resident #3 were sent to the Emergency Department (ED) for evaluation. The Report further indicated that Resident #4 was the only reported witness. The Report further indicated conclusion (final report) to follow. Review of the Facility's Investigation File, including an incident report and witness statements, identified two staff members as witnesses to the incident. However, review of the Investigation File indicated there was no documentation to support the allegation that Resident #2 pushed Resident #3 was investigated by the Facility. Further review of the File indicated there was no documentation to support that Resident #4 witnessed the altercation, as there was no record of an interview with Resident #4 and no written witness statement was obtained. Additionally, review of the Investigation File indicated the altercation occurred around 3:45 P.M., not at 8:30 P.M., as reported to DPH. These discrepancies regarding the time of the incident, the events that occurred, and the individuals who allegedly witnessed the altercation demonstrate that the investigation was not conducted thoroughly and that the information reported to DPH was not verified for accuracy prior to submission.Review of the Facility Incident Report, dated 04/28/26 at 3:45 P.M., indicated that Resident #3 was receiving staff assistance to adjust his/her clothing, when Resident #2 approached. The Report indicated that despite staff attempts to redirect Resident #2, Resident #3 punched Resident #2 in the nose. Review of Resident #3's Nurse Progress Note, dated 04/28/26, indicated that around 3:45 P.M. Resident #3 was in the hallway getting assistance from staff when Resident #2 approached him/her, and he/she responded by punching Resident #2 in the face. The Note indicated that Resident #3 was sent to the ED to be evaluated. Review of Resident #2's Nurse Progress Note, dated 04/28/26, indicated that around 3:45 P.M., Resident #2 approached Resident #3 in the hallway and despite staff intervention, he/she was struck in the face by Resident #3, resulting in a nosebleed. The Note indicated that Resident # 2 was sent to the ED for evaluation. Review of Certified Nurse Aide (CNA) #6's Written Witness Statement, dated 04/28/26, indicated that on 04/28/26 while she was assisting Resident #3 with his/her clothing, Resident #2 approached them. The Statement indicated that both she (CNA #6) and Nurse #3 attempted to intervene but were unable to prevent Resident #3 from hitting Resident #2 in the nose. Review of Nurse #3's Written Witness Statement, dated 04/28/26, indicated that on 04/28/26 at 3:45 P.M., she was speaking with CNA #6 while she assisted Resident #3 in the hallway when Resident #2 approached. The Statement indicated that despite intervention attempts by CNA #6 and herself (Nurse #3), Resident #3 struck Resident #2 in the face. During an interview on 05/27/26 at 4:00 P.M., the Director of Nurses (DON) said that she was not sure why there were discrepancies between the investigation and what was reported to the DPH in HCFRS. The DON also said they had no documentation to support their final investigative findings had been completed and submitted to DPH within five working days (by 05/05/26). The DON further said that she reported the time of the incident as 8:30 P.M., because that was when she was notified by staff that the incident had occurred.

Based on interviews, and record review, the facility failed to ensure a Registered Nurse (RN) worked eight (8) consecutive hours daily, as required. Specifically, the facility failed to ensure that a Registered Nurse worked at least eight consecutive hours daily on four days from 12/28/25 through 1/28/26. Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D form dated Quarter 4 2025 (July 1 through September 30), prior to survey entrance, indicated the facility triggered for excessively low weekend staffing. Review of the facility nursing schedule, dated 12/28/25 through 1/28/26, indicated no documented evidence that a RN worked at least eight consecutive hours on the following dates: -Sunday 1/4/26 -Saturday 1/10/26 -Saturday 1/17/26 -Sunday 1/18/26 On 1/29/26 at 9:26 A.M. through 9:55 A.M., the surveyor reviewed dates and employee punches/payroll data with the facility Scheduler. During an interview at this time, the Scheduler said the following she was aware of the requirement to have a RN in the facility daily but was not aware that there needed to be specific number of consecutive hours for the RN. The Scheduler said there was no RN that worked on Saturday 1/10/26, the scheduled RN for Saturday 1/17/26 must have called out, and no RN worked on that day, the scheduled RN for Sunday 1/18/26 worked from 10:40 A.M. until 4:15 P.M. (5.5 hours), the scheduled RN for Sunday 1/4/26 called out and the Director of Nursing (DON) was listed on the schedule to work from 7:00 P.M. to 11:00 P.M. (total 4 hours), and there were no other scheduled RN hours for 1/4/26. The Scheduler said she did not have access to the payroll information for the DON who was on listed on the schedule for Sunday 1/4/26, but Human Resources (HR) would be able to access the actual hours worked on that day. On 1/29/26 at 9:57 A.M., the HR Staff provided the detailed payroll information for Sunday 1/4/26. During an interview at the time, the HR Staff said the DON worked from 7:00 P.M. to 11:00 P.M. (4 hours total) on Sunday 1/4/26. During an interview on 1/29/26 at 11:18 A.M., the surveyor relayed concerns about the RN coverage to the Administrator and the Administrator said if the information for RN hours was reviewed with the Scheduler and the HR Staff, then the information about the RN hours was correct. The Administrator said the facility was currently in the process of onboarding nursing staff and the location of the facility has been a challenge in doing this.

Based on observations, interviews, and record review, the facility failed to ensure the main facility kitchen used to store, prepare and distribute resident food and beverages was maintained in a clean and sanitary manner in accordance with food service safety standards.Specifically, the facility failed to ensure that:-the fan in the dish room of the main facility kitchen was cleaned and kept free from dust blowing over clean pots and pans.-the dish rack housing clean dish ware and storage rack in the cook's preparation area was kept free of dust and debris to decrease the risk of physical contamination and foodborne illness. -areas in the main kitchen were appropriately cleaned as required and equipment stored per food safety standards. Findings include: Review of the facility policy titled Dietary Department Guidelines, undated, indicated the facility must store, prepare and distribute food under sanitary conditions. The policy also included the following: -The Dietary Department will be maintained in a clean and sanitary manner to prevent food borne illness. -All items stored in the refrigerator will be covered, labeled with the contents and the date. Review of the Food Drug Administration (FDA) Food Code 2017 (www.fda.gov), indicated the following: -Food Preparation: >During preparation, unpackaged food shall be protected from environmental sources of contamination. -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: >the objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. >Microorganisms may be transmitted from food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. >Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. >Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. >The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Cleaning, Frequency and Restrictions: >Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when food is in protected storage and when food is not being served or prepared. On 1/28/26 at 7:43 A.M., the surveyor conducted an initial walk through of the main facility kitchen with the Food Service Director (FSD), and the following was observed: -A pan of bagged raw chicken, dated 1/27/26 stored above a sheet pan of undated raw hamburger in the reach in refrigerator. -Three pitchers of unlabeled, undated juice in the reach in refrigerator. During an interview at the time, the FSD said items should be labeled and dated. -A large clear scoop exposed and placed on the outer top surface of the ice machine. The inner left side and top of the ice machine had white residue. During an interview at the time, the FSD said the ice machine needed to be cleaned. The FSD said there was a cleaning schedule for the ice machine and definitely needed to be done. The FSD said the scoop should not be stored on top of the ice machine because of potential contamination. -Fan which was on, located in the dish room, had copious amounts of dust and was blowing air over clean pots/pans and towards the clean end of the dish machine. During an interview at the time, the FSD said the fan needed to be cleaned. On 2/4/26 at 2:05 P.M., the surveyor conducted a follow-up tour of the kitchen with Dietary Aide (DA) #1, who was the Cook, and the following was observed: -Large clear scoop was exposed and placed on the outer top surface of the ice machine. During an interview at the time, DA #1 said the scoop was used to get ice out of the ice machine. DA #1 said the scoop should not be stored on top of the ice machine because it was open to air and potential infection. DA #1 said storing the scoop on top of the ice machine would increase the risk of contamination, and that it should be stored in its designated holder which was located on the wall. -Visible dust and dried debris were observed on a dish rack and on the wall behind the rack which housed clean dishware located in the dish room. During an interview at the time, DA #1 said she could not recall the last time the dish rack had been cleaned. DA #1 said there was a cleaning schedule used but after reviewing the schedule with the surveyor, DA #1 said the disk rack was not on the cleaning schedule. DA #1 said the dirty dish rack could be a contamination concern. -Storage rack located above the cook's preparation area where clean pots/pans were stored, had visible dust. -Storage area where numerous tongs were located had multiple white/tan dried drips. -Window above the preparation area had large dust spanning the left corner and expanding to the top and lower portion of the window. -Rotary toaster located below the window had greasy black debris and burnt black debris on the rotating rack. During an interview at the time, DA #1 said she could see the black debris on the toaster but was not sure who should clean the toaster. -A pitcher of unlabeled red liquids. During an interview at the time, DA #1 said the juice should have been labeled with contents and date. During an interview on 2/4/26 at 4:15 P.M., the surveyor relayed the kitchen sanitation concerns to the Administrator who said he understood the concerns.

Based on observations, interviews, and record review, the facility failed to ensure two Residents (#15 and #55) out of a total sample of 15 residents, were afforded dignity and privacy relative to use of their medical devices. Specifically, for Residents #15 and #55, the facility failed to ensure dignity for both Residents when privacy covers were not utilized for their urinary drainage bags. Findings include: Review of the facility policy titled Urinary Drainage Bag Policy, reviewed/revised January 2026, included the following: -Urinary drainage bags should be kept in privacy bags to maintain resident's dignity/privacy. 1. Resident #15 was admitted to the facility in May 2025 with diagnoses including Benign Prostatic Hyperplasia without lower urinary tract symptoms and urinary retention. Review of the Minimum Data Set (MDS) Assessment, dated 11/21/25, indicated Resident #15: -has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of a possible 15 points. -required substantial/maximum assistance of staff with toileting. -utilized an indwelling urinary catheter. Review of Resident #15's clinical record included the following: -Suprapubic Catheter Care Plan initiated 5/19/25. -Activities of Daily Living (ADL) Care Plan, initiated 5/16/25, which included the following intervention: >Provide privacy bag and promote dignity On 1/30/26 at 8:26 A.M., the surveyor observed Resident #15 dressed and ambulating with a walker in the hallway near the nursing station. A urinary drainage bag was observed hanging from the lower portion of the walker and the contents within the urinary drainage bag were visible. There was no privacy cover in place on the Resident's urinary drainage bag. On 1/30/26 at 9:47 A.M. and at 12:38 P.M., Resident #15 was observed dressed and ambulating with his/her walker around the nursing station. The urinary drainage bag remained on the lower portion of the walker and the contents within the urinary drainage bag were visible as there was no privacy cover in place on the urinary drainage bag. Several residents and staff were observed in the area at these times. On 2/4/26 at 3:00 P.M., the surveyor and Nurse #2 observed Resident #15 dressed and seated on the edge of the bed in his/her room. The Resident's walker was positioned in front of him/her and the urinary drainage bag was observed positioned on the lower portion of the walker with the contents of the urinary drainage bag visible, and no privacy cover in place. During an interview at the time, Nurse #2 said Resident #15's urinary drainage bag should be covered with a privacy bag. Nurse #2 said lack of a privacy bag is a concern relative to the Resident's privacy and dignity. 2. Resident #55 was admitted to the facility February 2018 with diagnoses including need for assistance with personal care and Neuromuscular Dysfunction of Bladder. Review of the MDS Assessment, dated 10/31/25, indicated Resident #55: -was cognitively intact as evidenced by a BIMS score of 14 out of 15 total points. -was dependent on staff for dressing and toileting. -utilized an indwelling urinary catheter. Review of the clinical record included the following: -Suprapubic Catheter Care plan initiated 7/23/24. -ADL Care plan, initiated 2/28/18, which included the following interventions: >Resident was dependent on staff for lower body dressing and toileting. >Provide privacy and promote dignity. On 2/4/26 at 2:15 P.M., the surveyor observed from the hallway Resident #55 was reclining in bed. The urinary drainage bag was observed laying on the floor at the end of the bed and there was no privacy cover on the urinary drainage bag, and the drainage bag contents were visible from the hallway. A Certified Nurses Aide (CNA) was also observed directly outside of the Resident's room and provided snacks/beverages to the Resident's roommate who was standing inside the room. On 2/4/26 at 3:00 P.M., the surveyor and Nurse #2 observed Resident #55 from the hallway outside of his/her room. The Resident was lying in bed and the urinary drainage bag remained on the floor at the end of the bed and was visible from the hallway. There was no privacy cover on the urinary drainage bag, and the contents of the bag were visible from the hallway. During an interview at the time, Nurse #2 said the Resident's urinary drainage bag should be off the floor and should be covered with a privacy bag. Nurse #2 said the Resident's visible urinary drainage bag was a dignity concern. During an interview on 2/4/26 at 3:48 P.M., the Regional Nurse said privacy bags should be provided for all residents with urinary catheters to promote dignity and privacy. Please refer to F880.

Based on record review, and interviews, the facility failed to ensure advanced directives were executed in accordance with the Resident's wishes for two Residents (#2 and #17), out of a total sample of 15 residents. Specifically, the facility failed to ensure the Resident and Resident Representatives wishes were honored in an emergency situation when:1.For Resident #2, the signed Massachusetts Medical Orders for Life Sustaining Treatment (MOLST - medical order form that relays instructions between health professionals about a patient's care based on an individual's right to accept or refuse medical treatment) Form which indicated to attempt resuscitation (Full Code) did not match the Physician orders which indicated Do Not Resuscitate (DNR)/ Do Not Intubate (DNI). 2.For Resident #17, the MOLST Form which indicated attempt resuscitation did not match the Physician orders which were initiated on 5/9/25 for DNR status. Findings include: Review of the facility policy titled Medical Orders for Life Sustaining Treatment MOLST (Massachusetts and Rhode Island), dated August 2015 indicated the following in part: -is a standardized form that is clearly identifiable -is recognized and honored across treatment settings -The MOLST will be reviewed by the facility interdisciplinary team during the quarterly care plan conference anytime there is a significant change in the resident's condition and at any time that the resident/patient or if the resident/patient lacks decision making capacity the legally recognized healthcare agent requests it. -At any time, a resident/patient with decision making capacity can revoke the MOLST form or change his/her mind about his/her treatment preferences either verbally or in writing or after consultation with the resident/patient's clinician by completing a new MOLST form. The new MOLST form must be signed by the clinician and the resident and the revoked MOLST must be voided. -All discussions about revising or revoking the MOLST should be documented in the medical record. This documentation should include the time and date of the discussion, the parties involved, the essence of the conversation and plans for follow-up action if needed. 1.Resident #2 was admitted to the facility in August 2022 with diagnoses including post-traumatic stress disorder, schizoaffective disorder, chronic kidney disease and malignant neoplasm of head, face and neck. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Health Care Proxy (HCP) was invoked. Review of Resident #2's Care Plan initiated on 8/3/22, indicated the Resident's HCP was invoked. Review of the MOLST Form signed by the HCP and the Nurse Practitioner on 8/2/22 indicated to attempt resuscitation. Review of the medical record indicated a form titled Comfort Care/Do Not Resuscitate ( DNR) Order Verification, (found in the Resident's physical chart in front of the MOLST form) was signed by the HCP on 1/5/26 and an Advanced Practice Registered Nurse (APRN) on 1/6/26. Review of the January 2026 Physician Order Summary Report indicated the following in part: -Code Status: Do Not Resuscitate (DNR)/Do Not Intubate (DNI), initiated on 1/26/26. During an interview on 2/2/26 at 3:08 P.M., the Nursing Supervisor said Resident #2 had been a full code, however when he/she went out to the hospital in January 2026, the HCP signed a DNR form while at the hospital. When Resident #2 returned to the facility, the Physician order was updated to reflect the HCP's wishes to change Resident #2's code status to a DNR. The Nursing Supervisor reviewed the electronic medical record (EMR) and the MOLST form found in the physical chart and said that the MOLST form indicated for the facility staff to attempt resuscitation and the EMR indicated DNR/DNI. The Nursing Supervisor said she could see how staff might be confused because the Physician order in the EMR did not match the MOLST found in the paper chart and that staff utilize both records to review a resident's code status in the event of an emergency. The Nursing Supervisor additionally pointed to the Comfort Care/Do Not Resuscitate ( DNR) Order Verification form and said this form could cause further confusion as staff will typically go right to the pink MOLST form, if they were going to the physical chart to obtain a resident's code status and skip right over this other form that is on a white piece of paper. During an interview on 2/4/26 at 11:54 A.M., Nurse #3 said if she were to find or be told that Resident #2 was unresponsive, she would do one of two things, if she was at the nurse's cart she would check the EMR. If she was not at the nurse's cart, she would grab the physical chart. Nurse #3 pulled out Resident #2's physical chart and went directly to the MOLST form. Nurse #3 said she believed the Resident to be a DNR, and she found it odd that the MOLST form indicated to attempt resuscitation. The surveyor turned the page to the Comfort Care/Do Not Resuscitate ( DNR) Order Verification form signed on 1/5/26 and Nurse #3 said that she did not see that form as it was a habit to go directly to the pink MOLST form. During an interview on 2/4/26 at 12:03 P.M., the Regional Nurse said because of the discrepancy in Resident #2's medical records, the facility staff might resuscitate a Resident who did not want to be resuscitated, and this would be very upsetting to the family. The Regional Nurse further said when the Resident returned from the hospital with a new Comfort Care/Do Not Resuscitate ( DNR) Order Verification form signed by the HCP on 1/5/26, the MOLST form should have been updated to reflect the new DNR wishes. 2.Resident #17 was admitted to the facility in April 2016 with diagnoses including schizoaffective disorder, traumatic brain injury and dementia. Review of the document titled Guardian's Care Plan/Report dated 3/29/21 indicated no evidence that the Guardian had expanded authority to elect advanced directives for Resident #17. Review of the January 2026 Physician order Summary Report indicated the following in part: -Code Status: DNR, initiated on 5/9/25. Review of the EMR dashboard (home screen when a Resident's EMR is first opened on the computer) indicated the following: -Code Status: DNR Review of the MOLST Form, found in Resident #17's paper chart located at the nurse's station, signed by the Guardian on 12/20/19 and the Nurse Practitioner (NP) on 1/7/20 indicated to attempt resuscitation. Review of a form titled State of [sic] Department of Public Health Transfer of Do Not Resuscitate Order indicated the following: -DNR order, date 5/6/25 -Original DNR order by a name with no designation of Physician or Advanced Practice Registered Nurse (APRN) -Signed by a Registered Nurse on 5/8/25 -Not signed by the Guardian -. When a patient who is to be transferred between healthcare institutions has a DNR order which is to remain in effect during and after the transfer. During an interview on 1/29/26 at 10:07 A.M., Nurse #1 said if she were to find a resident unresponsive, she would go to whatever is closer, the computer or the physical chart to locate the residents' code status. Nurse #1 then demonstrated on the computer where she would locate the code status for Resident #17. Nurse #1 went directly to the dashboard of Resident #17's EMR and said the code status was DNR. Nurse #1 said she would additionally look under miscellaneous in the EMR to try and locate the official MOLST Form. Nurse #1 said if she was unable to locate the MOLST Form in the EMR, she would then go to the paper chart because she preferred to see the MOLST form in writing as she felt that was the most up to date information. Nurse #1 further said that the Resident Representative had recently signed Resident #17 onto hospice services, and she believed him/her to be a DNR. During a follow-up interview on 1/29/26 at 10:22 A.M., the surveyor and Nurse #1 reviewed the MOLST Form found in Resident #17's physical chart located at the nurse's station. Nurse #1 said the MOLST Form indicated attempt resuscitation and did not match the EMR which indicated DNR. Nurse #1 said in this circumstance she would attempt resuscitation. During an interview on 1/29/26 at 11:04 A.M., with the Regional Social Worker and the Director of Social Services, the Regional Social Worker reviewed the form titled State of [sic] Department of Public Health Transfer of Do Not Resuscitate Order and said she was unfamiliar with the form but it appeared to be signed by a Physician and indicated the Resident would be a DNR. The Regional Social Worker said she believed that this occurred while Resident #17 was at the hospital in May 2025. The Regional Social Worker said she believed the hospital spoke with the Guardian, and it was determined that the Resident should be a DNR due to his/her decline in health. The Regional Social Worker said when a Resident returned from the hospital, the facility process was during the next morning meeting (following a resident's return from the hospital), the team would review the discharge information provided by the hospital, including changes in Physician orders and/or advanced directives and ensure the changes were accurate and addressed appropriately. The Regional Social Worker further said she could not verify that Resident #17's advanced directives had been reviewed by the team since the change in his/her code status, but the Physician orders had been changed on 5/9/25 to reflect a DNR code status. The Regional Social Worker said she reviewed the Guardianship, and it appeared that the Guardianship did not indicate the Guardian had expanded authority to make decisions relative to Resident #17's advanced directives. The Regional Social Worker further said she was unsure why the current January 2026 Physician orders or the State of [sic] Department of Public Health Transfer of Do Not Resuscitate Order indicated DNR as the Guardian did not have authority to make those decisions (change the advanced directives). During an interview on 1/29/26 at 11:50 A.M., Resident #17's Guardian said he/she recently agreed to sign Resident #17 onto hospice services, because of his/her change in condition. The Guardian said the decline was concerning and scary to him/her because he/she understood that he/she needed to make a difficult decision for Resident #17. The Guardian further said when Resident #17 was well, the Guardian and Resident #17 discussed that Resident #17's wishes were to not be kept alive by machines. The Guardian said when he/she spoke with hospice services last week, the code status was reviewed and the Guardian wanted to ensure the Resident was a DNR/DNI/DNH (Do Not Hospitalize), to honor Resident #17's wishes. The Guardian said he/she could not recall discussing advanced directives, code status or wishes with the facility recently and was unaware of any limitation he/she had as the Guardian of Resident #17. During a follow-up interview on 1/29/26 at 2:14 P.M., the Regional Social Worker said she spoke with the facility's legal team, the legal team reviewed the Guardianship and determined that the Guardian did not have authority to make advanced directive decisions at this time. The Regional Social Worker said at this time the facility would revert to Resident #17 being designated as a full code and initiated the process to obtain expanded authority for the Guardian to make advanced directive decisions. The Regional Social Worker said she is not sure where the system broke down as it is the company's expectation that residents returning from the hospital will be reviewed during the next morning meeting to review any changes. The Regional Social Worker said had this process occurred the facility could have initiated the process to obtain expanded authority so the Guardian could make advanced directive decisions months ago and there would have been no confusion on Resident #17's code status.

Based on interviews, and record review, the facility failed to ensure Notices of Transfer or Discharge and Bed Hold were provided to residents or their resident representatives at the time of transfer or shortly thereafter and that the Office of the State Long-term Care Ombudsman was notified at the time of transfer or shortly thereafter for four Residents (#1, #10, #17, and #57), of five applicable Residents reviewed for hospitalizations, out of a total sample of 15 active records and one closed record. Specifically, the facility failed to ensure Resident's #1, #10, #17, and #57 and/or their Representative were provided a copy of the facility Bed Hold policy, a Notice of Intent to Transfer upon transfers to the hospital or shortly thereafter. The facility also failed to ensure that the Office of the State Long-term Care Ombudsman was notified when the Residents were transferred from the facility to the hospital for evaluation. Findings include: 1. Resident #1 was admitted to the facility in January 2014. Review of Resident #1's clinical record included the following: -Nurse's Note dated 8/23/25, 911 was called and Resident's Representative was notified of the Resident's transfer to the hospital. -Nurse's Note dated 8/29/25, Resident returned to the facility. Further review of Resident #1's clinical record indicated: -No documented evidence that the Intent to Transfer and Bed Hold policy were provided to the Resident/Resident Representative upon transfer or shortly thereafter. -No documented evidence that the Office of the State Long-Term Ombudsman was notified of the Resident's transfer. 2. Resident #10 was admitted to the facility in June 2021. Review of Resident #10's clinical record indicated the following: -Nurse's Note dated 12/7/25, Resident's skin became clammy, very cool to the touch and color was very white .speech was garbled .sent out to the hospital for evaluation. -Nurse's Note dated 12/16/25, Resident returned to the facility from the hospital . Further review of Resident #10's clinical record indicated: -No documented evidence that the Intent to Transfer and Bed Hold policy were provided to the Resident/Resident Representative upon transfer or shortly thereafter. -No documented evidence that the Office of the State Long-Term Ombudsman was notified of the Resident's transfer. 3. Resident #17 was admitted to the facility in April 2016. Review of Resident #17's clinical record indicated the following: -Nurse's Note dated 1/22/26, Resident had an unwitnessed fall with pain, redness and swelling to his/her right hip. The Provider was updated and the Resident was sent to the hospital for further evaluation. -Nurse's Note dated 1/23/26, Resident returned from the hospital . Further review of Resident #17's clinical record indicated: -No documented evidence that the Intent to Transfer and Bed Hold policy were provided to the Resident/Resident Representative upon transfer or shortly thereafter. -No documented evidence that the Office of the State Long-Term Ombudsman was notified of the Resident's transfer. 4. Resident #57 was admitted to the facility in June 2021. Review of Resident #57's clinical record indicated the following: -Nurse's Note dated 12/18/25, Resident had a physical altercation with another resident. Provider was updated and gave an order to transfer the Resident to the hospital for evaluation . -Nurse's Note dated 12/21/25, Resident returned from the hospital . -Nurse's Note dated 1/8/26, Resident noted to have shortness of breath and was wheezing. Resident's family was notified and agreed to send the Resident out to the hospital for evaluation . Further review of the Resident #57's clinical record indicated: -The Resident did not return to the facility after the transfer to the hospital on 1/8/26. -No documented evidence that the Intent to Transfer and Bed Hold policy were provided to the Resident/Resident Representative upon transfer or shortly thereafter. -No documented evidence that the Office of the State Long-Term Ombudsman was notified of the Resident's transfer. During an interview on 1/30/26 at 2:33 P.M., the Regional Nurse said when a resident is transferred out of the facility, a copy of the facility Bed Hold policy and an Intent to Transfer notice would be completed and provided to the resident/resident representative and copies provided to the Office of the State Long-Term Ombudsman. The Regional Nurse said the nursing staff would document in the resident's clinical record that this task was completed and copies of these forms would be located in the resident's clinical record. The Regional Nurse was unable to find evidence that the Intent to Transfer and facility Bed Hold policy had been provided to the Residents/Resident Representatives when Resident's # 1, #10, #17 and #57 were transferred to the hospital. The Regional Nurse was also unable to find evidence that the Office of the State Long-Term Ombudsman had been notified of Resident's #1, #10, #17, and #57 transfers and had been provided with the transfer/bed hold notices as required.

Based on record review, and interviews, the facility failed to notify the State Mental Health Authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#1) out of a total sample of 15 residents. Specifically, the facility failed to complete and request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness and if a Resident is in need of additional specialized support services at the facility) after Resident #1 received emergency mental health support due to mental illness on two occasions.Findings include:Review of the facility protocol titled PASRR Quick Reference, updated 7/30/25 indicated the following in part:-Why do you submit a PASRR Level I in the portal?---Something has changed with the resident (i.e. went out to the hospital for a psych eval or overdose.)-PASRR should be reviewed at morning meeting the following business day after the resident is admitted ensuring a PASRR is completed. Resident #1 was admitted to the facility in January 2014 with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder. Review of a Nursing Progress Note dated 9/11/25 indicated Resident #1:-stated that he/she wanted to kill him/herself to a few staff members.-was sent out to the emergency room for a psych evaluation.-told the Police officer that if he/she was serious he/she had things in his/her room to do it. Review of the Hospital Discharge summary dated [DATE] indicated Resident #1 was seen for suicidal ideation. Review of Resident #1's Behavioral Progress Note dated 10/1/25 indicated:-Resident reported feeling down, depressed, and hopeless.-Resident stated he/she would cause harm to him/herself.-When asked directly about suicide he/she expressed, he/she thought of suicide.-When asked directly if he/she had a plan, he/she expressed he/she had a plan but would not elaborate. Review of Resident #1's Nursing Progress Note dated 10/1/25 indicated:-Nurse was notified that the Resident was suicidal and had a plan.-On-call Provider was notified and instructed the Nurse to obtain a Section 12 (a Massachusetts law that allows the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation). Review of the Hospital Discharge summary dated [DATE], indicated Resident #1 was seen for thoughts of suicide and screened by the crisis team.Further review of the medical record failed to indicate documented evidence that the facility notified the State Mental Health Authority for a resident review after Resident #1 received emergency mental health support due to mental illness on 9/11/25 and 10/1/25. During a telephone interview on 2/2/26 at 11:38 A.M., the Regional Social Worker said any time someone is sent out for any change in mental health the facility would do a PASRR resident review upon return. During a follow-up interview on 2/2/26 at 2:00 P.M., the Regional Social Worker said she reached out to the PASRR office to see if a PASRR resident review had been submitted for either of the significant mental health changes for Resident #1 on 9/11/25 and 10/1/25 and noted that nothing had been sent to the PASRR office. The Regional Social Worker further said she would have expected a resident review to have been submitted so that the PASRR office would have an opportunity to determine if Resident #1 was positive for Level II screening which could promote specialized service. The Regional Social Worker said that the Director of Social Services had been working on obtaining access to the PASSR portal but currently did not have access. Please refer to F657

Based on observation, interviews, and record review, the facility failed to ensure the person-centered plan of care was revised for two Resident's (#1 and #6), out of a total sample of 15 residents. Specifically, the facility failed to ensure:For Resident #1, care plans were updated when he/she voiced suicidal ideations resulting in the Resident being sent out for a psychiatric evaluation to be conducted at the hospital on two occasions. For Resident #6, nutrition interventions recommended by the Dietitian were reviewed with the Resident's Provider timely and interventions implemented to assist with healing of the Resident's wounds, placing him/her at risk for potential delay in wound healing. Findings include:Review of the facility policy titled Comprehensive Care Plans, revised 11/2017 indicated the following: -Care plans are a combination of: ---Data concerning the resident that is obtained from the physician ---Clinical records such as the hospital discharge summary ---Evaluations done by professional and other disciplines ---The resident and/or family goals for treatment ---Acute chronic events behaviors and or illness -Based on the above, the interdisciplinary team develops a comprehensive care plan for each resident that includes measurable outcomes and timelines to accommodate preferences, special medical nursing, and psychosocial needs identified in the assessment -The care plan is evaluated and revised as needed but at least quarterly 1.Resident #1 was admitted to the facility in January 2014 with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder. Review of a Nursing Progress Note dated 9/11/25, indicated Resident #1 was stating to a few staff members that he/she wanted to kill him/herself. Resident #1 was sent out to the emergency room for evaluation, and the Resident told the Police Officer that if he/she was serious he/she had things in his/her room to do it. Review of hospital Discharge summary dated [DATE], indicated Resident #1 was seen for Suicidal Ideation. Review of a Behavioral Progress Note dated 10/1/25, indicated Resident #1 reported feeling down, depressed, and hopeless and that he/she would cause harm to him/herself. When Resident #1 was asked directly about suicide, he/she expressed that he/she thought of suicide. When the Resident was asked directly if he/she had a plan, he/she expressed he/she had a plan but would not elaborate. Review of a Nursing Progress Note dated 10/1/25, indicated the Nurse was notified that Resident #1 was suicidal and had a plan. The on-going Provider was notified and instructed the Nurse to obtain a Section 12 from the Physician and transfer the Resident to the emergency room. Review of hospital Discharge summary dated [DATE], indicated Resident #1 was seen for thoughts of suicide and screened by the crisis team. Review of Resident #1's Psychosocial Well-Being Care Plans initiated 1/16/14 and revised 3/31/25, indicated: -Anxiety, suicide ideation. -Interventions in place, initiated on 1/16/14. Further review of the medical record failed to indicate any documented evidence that the facility updated the Resident's Care Plan after Resident #1 received emergency mental health support on 9/11/25 and 10/1/25. During an interview on 2/2/26 at 10:27 A.M., the Director of Social Services said when a resident returns from a hospitalization relative to suicidal ideations, the care plan should be updated and include individualized interventions as well as any recommendation made by the hospital. The Director of Social Services further said it appeared the care plans had not been updated for Resident #1 and was unable to provide additional information. During an interview on 2/2/26 at 10:49 A.M., the Regional Nurse said the facility staff would follow the facility policy when residents had suicidal thoughts, that would include updating the care plans. The Regional Nurse reviewed Resident #1's care plans and said that she would have expected the care plans to be updated with information specific to Resident #1 and relative to suicidal ideations, however they had not been since 2014. 2. Resident #6 was admitted to the facility in January 2025 with diagnoses including atherosclerosis of arteries of the left leg with ulceration and Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene and Adult Failure to Thrive. Review of the facility policy titled Consultant Services, dated April 2015, indicated the facility will identify and facilitate consultant to meet the resident's needs to ensure optimum care for each resident/patient through consultant services. The policy also included the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident . -The consultant should document findings and recommendations . -The charge nurse will notify the attending physician of findings, and he/she can then order outlined by the consultant -A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record. Review of the Minimum Data Set (MDS) Assessment, dated 1/9/26, indicated Resident #6: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. -had two arterial ulcers present. Review of Resident #6's Alteration in Skin Integrity Care Plan, initiated 2/2/25, indicated Resident #6 had non-pressure/vascular areas to his/her left outer ankle and lateral lower leg, included the following interventions: -Administer antibiotic therapy as ordered by the Physician -Follow Physician's order for skin care and treatments. Utilize best practice guidelines Review of the Dietitian Progress Note, dated 1/24/26, indicated: -was updated on the Resident's vascular wound that has not healed. -Recommended: >L-arginine powder 5 grams (gm) twice daily with Zinc 8-11 milligrams (mg) for ten days and off 10 days until wound is healed. >Vitamin C 250 mg twice daily. Review of the February 2026 Physician's orders included the following: -Treatment order: cleanse left lateral ankle wound .initiated 2/3/26 -Treatment order: apply skin prep to left anterior lower extremity .initiated 12/9/25 -Treatment order: cleanse right abraded area initiated 1/28/26 -Levaquin (antibiotic) 500 mg daily for possible cellulitis to right lower extremity for seven days, initiated 1/28/26 Review of the Resident's clinical record failed to indicate documented evidence of the response to the Dietitian's recommendations made on 1/24/26. During an interview on 2/2/26 at 4:19 P.M., the Dietitian said she relays her recommendations in the interdisciplinary progress notes and links these recommendations so that they can be reviewed by nursing and Physician. The Dietitian said in addition, she thinks that she verbally relayed these recommendations to the Nurse who had asked her to look into the concern with the Resident's vascular wounds that were not healing. The Dietitian said L-Arginine is a source of protein and would assist with wound healing and the Vitamin C would assist with preventing infection. During an interview on 2/4/26 at 1:21 P.M., the Assistant Director of Nurses (ADON) said the Dietitian has access to the electronic medical records for residents. The ADON said the Dietitian's recommendations for pharmacy type orders like L-arginine, Vitamin C, and Zinc would be in a progress note that would be flagged or linking in the progress notes and then would show up in the 24-hour report that nursing and administration reviewed daily. The ADON said she reviewed the 24-hour reports, and these recommendations were not linked/flagged relative to Resident #6's recommendations from 1/24/26. During an interview on 2/4/26 at 1:30 P.M. and 3:40 P.M., the Regional Nurse said the Resident's Provider was updated today (2/4/26) relative to the Dietitian's recommendations from 1/24/26 and approved the recommendations. The Regional Nurse said the expectation would be that once the Dietitian had made recommendations, the nursing staff would notify the Provider within 24 hours to approve or decline the recommendations. The Regional Nurse said that she would also expect a Nurses' note to be written with what occurred relative to the Dietitian recommendation. The Regional Nurse said there was a system breakdown which resulted in a delay in treatment for Resident #6. The Regional Nurse said the Dietitian's recommendations were for wound healing and malnutrition and that these recommendations were not addressed until today (11 days later).

Based on observation, interview, and record review, the facility failed to assist one Resident (#42), out of a total sample of 15 residents, in obtaining routine dental services.Specifically, the facility failed to schedule dental appointments to ensure that Resident #42 received routine dental services as ordered. Findings include: Review of the facility policy titled Dental Services/Dentures dated April 2015 indicated the following:-Dental services will be provided to each resident, as needed, by a qualified dentist, as part of the facility's oral health program.-Staff will assist residents in obtaining routine and emergency dental care.-Services will be provided by the resident's dentist of choice or by the facility's consulting dentist.-The appropriate health care professional will document the provision of dental services and oral hygiene procedures in the resident's clinical record. Resident #42 was admitted to the facility in November 2024 with diagnoses including Dementia, Dysphagia and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #42 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a total possible score of 15. On 1/28/26 at 11:11 A.M., the surveyor observed Resident #42 had jagged, and missing teeth. The surveyor also observed the Resident was chewing on his/her tongue. During an interview at the time, Resident #42 said he/she had teeth hanging down in his/her mouth and the facility would not let him/her see a Dentist. Review of the active Physician orders for Resident #42 indicated the following:-Consults: Dental care as needed, last revised 11/14/24 Review of Resident #42's Care Plan, last revised 10/13/25 indicated:-has poor dentition-will have no difficulty chewing-Dental consult as needed-monitor for difficulty chewing or swallowing-provide assistance with oral care every shift, after meals Review of the facility Oral Health evaluations dated 6/24/25, 10/22/25, and 1/23/26 indicated that based on the evaluation and observation at the time of the oral health exam, Resident #42 required routine mouth care. Review of the clinical record failed to provide any evidence that Resident #42 had been offered or received routine dental services while residing in the facility. During an interview on 1/30/26 at 10:37 A.M., the Regional Nurse said that Resident #42 should have been seen by the Dentist at some time since admission to the facility and that all residents should be seen by the Dentist annually. The Regional Nurse also said that she would review the Resident's last oral evaluation completed 1/23/26 and perform her own oral evaluation for Resident #42. During an interview on 1/30/26 at 10:59 A.M., the Director of Nursing (DON) said that all Residents should be seen by the Dentist routinely every six months to one year. The DON said she was not sure when the Dentist last visited the facility and that she would find out when Resident #42 had last been seen by the Dentist. During a follow-up interview on 1/30/26 at 11:05 A.M., the Regional Nurse said that she had completed an oral health exam for Resident #42 and that the Resident had missing teeth and was biting his/her tongue. The Regional Nurse also said that the Resident definitely needed to see a Dentist and the Resident should have had routine dental services in place.

Based on observations, interviews, and record review, the facility failed to ensure infection control standards were implemented for two Residents (#6 and #55), out of a total sample of 15 residents. Specifically, For Resident #6, the facility failed to minimize the potential spread for infection during a wound dressing change when the Nurse did not change gloves and perform hand hygiene as required increasing the potential for contamination and wound infection. For Resident #55, the facility failed to ensure the urinary drainage bag was maintained off the floor, and that facility staff donned the required personal protective equipment (PPE) when handling the urinary drainage bag. Findings include:1. Resident #6 was admitted to the facility in January 2025 with diagnoses including atherosclerosis of arteries of the left leg with ulceration and Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene. Review of the facility policy titled Clean Dressing Technique, undated, indicated non-sterile dressings protect wounds from contamination and absorb drainage. The policy also included the following:-Licensed staff members will use clean dressing technique for all dressing changes unless otherwise specified by the Medical Doctor (MD).-Gather supplies and place on clean field, including several clean gloves.-Sanitize hands and apply clean gloves.-Remove old dressing and discard in plastic bag.-Remove gloves, sanitize hands and apply clean gloves.-Cleanse wound with solution ordered. Cleanse from the center of the wound to the periphery.-Remove gloves, sanitize hands and apply clean gloves. -Apply any medication ordered and dress wound.-Remove gloves and sanitize hands. Review of the Minimum Data Set (MDS) Assessment, dated 1/9/26, indicated Resident #6:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points-has two arterial ulcers present. Review of Resident #6's Alteration in Skin Integrity Care Plan, initiated 2/2/25, indicated Resident #6 had non-pressure/vascular areas to his/her left outer ankle and lateral lower leg, and included the following interventions:-Administer antibiotic therapy as ordered by the Physician-Follow Physician's order for skin care and treatments. Utilize best practice guidelines. Review of the February 2026 Physician's orders indicated:-Treatment Order: apply skin prep daily to left anterior lower leg every day shift for wound care, initiated 12/9/25. -Treatment Order: cleanse left lateral ankle wound with normal saline (NS), apply 0.25 Dakin's solution to packing strip then apply to wound bed, cover with Vaseline gauze then cover with ABD (absorbent dressing) pad and wrap with Kerlix each day and PRN (as needed) if soiled or displaced. Apply house antifungal cream to peri-wound Q (every) day, every day shift and every 4 hours, may change dressing PRN if soiled and displaced. Apply house anti-fungal cream to peri-wound each day, initiated 2/3/26.-Cleanse right lower extremity abraded/area with NS (Normal Saline), apply triple antibiotic ointment and cover each day with DCD (dry clean dressing) and PRN if soiled or displaced, initiated 1/28/26.-Minerin Cream (generic Eucerin) to bilateral lower extremities twice daily and as needed, initiated 1/23/26.-Levaquin 500 milligrams (mg) daily for possible cellulitis to right lower extremity for seven days, initiated 1/28/26. On 2/4/26 at 2:30 P.M. through 2:50 P.M., the surveyor observed Nurse #2 perform the dressing changes for Resident #6's wounds and observed the following:-An over-bed table with clean towel and wound supplies was positioned next to the Resident's bed. Two pairs of gloves were observed on the clean towel. -Resident #6 was dressed and seated in a wheelchair next to the bed.-Nurse #2 had on a gown, surgical mask and was observed to put on (don) one pair of gloves from the clean towel.-Nurse #2 removed the Resident's dressing on the left ankle and discarded the soiled dressing in the trash.-Nurse #2 removed the dressing from the back of the Resident's left leg and discarded the soiled dressings and packing strips into the trash.-Nurse #2 cleansed the wound areas with presoaked gauze containing NS, using the same gloves that removed the soiled dressings.-Nurse #2 used the same soiled gloved hands to wave air over the wounds to dry the Resident's skin.-Nurse #2 then applied Minerin ointment to the Resident's left leg using the same gloved hands.-Nurse #2 used her finger of the same soiled gloves to reach into a medication cup containing skin prep and apply the skin prep around the left leg wounds.-Nurse #2 used her gloved fingers, reached into a medication cup containing presoaked gauze strips in 0.25 Dakins solution, removed the strip and applied the strip to one of the Resident's left leg wound and then repeated the same to the second leg wound. -Nurse #2, using the same soiled gloves, applied folded xeroform dressings to the wounds, and then wrapped the Resident's left lower leg with kerlix wrap.-Nurse #2 removed her gloves, performed hand hygiene and donned a new pair of gloves which were on the towel with the wound supplies. -Nurse # 2 was observed to use gloved hands to wash the Resident's right shin with gauze presoaked with NS and discarded the soiled gauze into the trash.-Nurse #2 then used the same gloved hands to pick up a piece of dry gauze and gently dried the Resident's right front shin and discarded the used gauze into the trash.-Nurse #2 put a gloved finger into a medication cup containing triple antibiotic ointment and applied the ointment to the Resident's right shin areas using her gloved finger.-Nurse#2 wrapped the Resident's right lower leg with kerlix wrap, removed her PPE (gown and gloves), discarded them into the trash, performed hand hygiene, and removed the towel containing the wound products from the Resident's room. During an interview immediately following the wound care observation, Nurse #2 said gloves should be removed after removing old wound dressings and hand hygiene performed before applying new gloves and prior to applying the new clean wound dressings. Nurse #2 said she did not discard her gloves until she completed the entire wound treatments for the Resident's left leg. Nurse #2 said by not removing her gloves and performing hand hygiene when required could increase the risk for contamination and potential infection in the Resident's wounds. During an interview on 2/4/26 at 3:48 P.M., the surveyor discussed the wound dressing care observations with the Regional Nurse. The Regional Nurse said glove changes and hand hygiene should occur throughout the wound dressing changes and by not changing gloves and performing hand hygiene after removing old dressings, cleaning the wound, and applying new dressings, the risk of contamination and infection would increase. 2. Resident #55 was admitted to the facility in February 2018 with diagnoses including need for assistance with personal care and neuromuscular dysfunction of the bladder. Review of the facility policy titled Enhanced Barrier Precautions (EBP), undated, indicated it was the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). The policy also included the following:-EBP require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multidrug-resistant organisms. -High-contact resident care activities include .providing hygiene, transferring, toileting, device care .-EBP will be implemented for residents with indwelling medical devices ( .catheters .) Review of the MDS Assessment, dated 10/31/25, indicated Resident #55: -was cognitively intact as evidenced by a BIMS score of 14 out of 15 total points. -was dependent on staff for dressing and toileting. -utilized an indwelling urinary catheter. On 2/4/26 at 2:15 P.M., the surveyor observed Resident #55 lying in bed and the Resident's uncovered urinary drainage bag was laying on the floor and yellow contents was observed within the bag. EBP signage was observed posted outside of the Resident's room. On 2/4/26 at 3:00 P.M., the surveyor and Nurse #2 observed from the hallway, Resident #55 lying in bed and his/her urinary drainage bag remained on the floor with the contents of the urinary drainage bag visible. During an interview at the time, Nurse #2 said the Resident's urinary drainage bag should not be on the floor, was an infection control concern and an increased risk of contamination. Nurse #2 entered the Resident's room, did not perform hand hygiene or put on a gown and gloves, and was observed to pick up the Resident's urinary drainage bag from the floor and attempted to secure it to the side of the Resident's bed frame. During an interview on 2/4/26 at 3:48 P.M., the Regional Nurse said Resident #55's urinary drainage bag and tubing should be off the floor and that if the urinary drainage bag was laying on the floor, this would be an infection control concern. The Regional Nurse said the hooks on the urinary drainage bags should be secured to the end of the Resident's bed. The Regional Nurse further said that when Nurse #2 went to adjust the Resident's urinary drainage bag, she should have performed hand hygiene and put on a gown and gloves.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment, the Facility failed to ensure he/she was free from abuse from a staff member, when on 08/09/25, while Nurse #1 was assisting Resident #1, he/she grabbed and squeezed Nurse #1's hand, and in response she struck Resident #1 on the back and pulled his/her hair in attempt to release his/her grip. Nurse #1 admitted to engaging in a physical altercation with Resident #1 and the incident was witnessed by another staff member, and an alert and oriented resident. A cognitively intact person would likely experience pain, anger and emotional distress if struck and had their hair pulled by a caregiver. Findings include:Review of the Facility Abuse, Neglect and Exploitation Policy, implemented February 2023, indicated that it was the policy of the Facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The Policy indicated that the definition of abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/09/25, indicated that at 6:04 P.M. Nurse #2 reported that Nurse #1 engaged in physical contact with Resident #1 after he/she grabbed her (Nurse #1). The Report indicated that Resident #1 was calling out for help, stood from his/her wheelchair, and that Nurse #2 responded along with Nurse #1 to prevent him/her from falling. The Report indicated that Resident #1 pinched Nurse #1 on the buttocks and that when she went to push his/her hand away, he/she grabbed Nurse #1's closed hand and squeezed, causing her pain. The Report indicated that Nurse #1 said that she pulled Resident #1's hair to get him/her to release his/her grip and when that did not work, she pinched his/her arm. The Report indicated that Nurse #2 witnessed Nurse #1 slap Resident #1's back and pull his/her hair, and that she (Nurse #2) grabbed Nurse #1's hand and said, No, you can't do that! The Report indicated that when Resident #1 released Nurse #1's hand, she pulled away and yelled, I am done with this fucking place, let him/her fall, I will send him/her out!The Report further indicated that Resident #2 witnessed the physical altercation between Resident #1 and Nurse #1, and that Resident #1 had no recollection of the event. The Report indicated that Resident #2 heard Nurse #1 use profanity as she walked away from the incident.Based on the reasonable person concept, it would be more likely than not, that Resident #1 would have experienced psychosocial harm, recurrent fear, anxiety, anger, or pain as a result of the physical abuse since there is an expectation that he/she would not be hit or have his/her hair pulled by a provider that had been entrusted to care for him/her.Resident #1 was admitted to the Facility in June 2025, diagnoses included vascular dementia, psychotic disorder with delusions, generalized anxiety disorder and repeated falls. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 06/10/25, indicated he/she was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact)Resident #2 was admitted to the Facility in November 2024 with diagnoses including Parkinson's Disease. Resident #2's Quarterly MDS Assessment, dated 05/23/25, indicated he/she was moderately cognitively impaired with a score of 11 out of 15 on the BIMS.During an interview on 10/16/25 at 1:27 P.M. Resident #2 said that he/she witnessed a physical altercation between Nurse #1 and Resident #1, at the nurses' station, that occurred a few months ago (exact date and time unknown). Resident #2 said Resident #1 was repeatedly calling out for help and continually attempting to stand from his/her wheelchair just before the incident.Resident #2 said that Resident #1 eventually stood up from his/her wheelchair and that when Nurse #1 approached to assist him/her, Resident #1 grabbed her hand. Resident #2 said that he/she then observed Nurse #1 strike Resident #1 on his/her back with her open hand. During an interview on 10/17/25 at 12:19 P.M. (which also included a review of her written witness statement dated 08/09/25) Nurse #1 said that she worked the evening shift on 08/09/25. Nurse #1 said that Resident #1 had returned from the hospital that morning following a fall, during which he/she sustained fractured ribs. Nurse #1 said she was familiar with Resident #1 noting that he/she had dementia and was at risk of falls. Nurse #1 said that Resident #1 was restless that evening and may have been experiencing discomfort from his/her fractured ribs. Nurse #1 said that at approximately 6:00 P.M. Resident #1 attempted to stand up from his/her wheelchair by the nurses' station, indicating that he/she needed to use the bathroom. Nurse #1 said she encouraged Resident #1 to sit back down because she didn't have the opportunity to assist him/her and was unsure if his/her transfer status had changed since his/her recent fall. Nurse #1 said that Resident #1 then stepped one foot over the padded footrests of his/her wheelchair, causing him/her to stumble and lean on her for support. Nurse #1 said that Resident #1 began hitting and pinching her hip and when she went to push his/her hand away, he/she grabbed her right hand and squeezed it tightly, causing pain. Nurse #1 said that she did not know how to make Resident #1 release her hand, that she just reacted, she pinched Resident #1's arm and pulled the hair at the base of his/her neck in an attempt to make him/her let go but was unsuccessful.Nurse #1 said that Nurse #2 stated to her, What are you doing? and she responded that Resident #1 was hurting her hand. Nurse #1 said that Nurse #2 was able to convince Resident #1 to release her (Nurse #1) hand. Nurse #1 said that as soon as Resident #1 let go, she immediately stepped away from the situation.Nurse #1 said that she had been feeling overwhelmed by the noise and activity on the unit that evening, in addition to her regular job duties. Nurse #1 said that she should not have reacted by engaging physically with Resident #1, that she should have attempted to de-escalate the situation, but said she was unsure how to do so at the time. During an interview on 10/17/25 at 11:44 A.M. (which also included a review of her written witness statement dated 08/09/25) Nurse #2 said that Resident #1 was seated in his/her wheelchair, by the nurses' station for increased supervision due to restlessness and a risk of falls. Nurse #2 said that around 6:00 PM on 08/09/25, she and Nurse #1 responded when Resident #1 stood up from his/her wheelchair, to prevent a possible fall. Nurse #2 said she observed Nurse #1 strike Resident #1 on the back and pull the hair on the back of his/her neck causing his/her head to tilt backward. Nurse #2 said she instructed Nurse #1 to stop and told her that such actions were not appropriate. Nurse #2 said that Nurse #1 told her that Resident #1 had a hold of her hand and was causing her pain. Nurse #2 said she was able to assist in having Resident #1 release his/her grip. Nurse #2 said that immediately following the incident, Nurse #1 told her (while still in the presence of Resident #1 and #2), I hate this fucking place. Let [Resident #1] fall, I will send him/her out, and then Nurse #1 left the area. During an interview on 10/16/25 at 3:17 P.M. the Administrator said the outcome of the Facility's Internal Investigation was that the allegation of physical abuse was substantiated and that Nurse #1's employment at the Facility was terminated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted , was unfamiliar with the facility, the staff, and was having difficulty adjusting to his/her admission, the Facility failed to ensure he/she was free from abuse, when on 05/01/25 at approximately 1:30 P.M., Director of Nurses (DON) #1 engaged in a verbally and physically abusive altercation with Resident #1. DON #1 with the assistance of Certified Nurse Aide #1, physically restrained Resident #1 to retrieve a bottle of medication he/she had in his/her possession, they pinned him/her up against the wall, blocked him/her from exiting the area, held him/her by his/her arms, pried open his/her hand to check for pills and searched his/her pockets, which only served to escalate Resident #1's resistive and combative behaviors. Findings include: Review of the Facility Abuse, Neglect and Exploitation Policy, implemented February 2023, indicated that it was the policy of the Facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The Policy indicated that the definition of abuse included unreasonable confinement. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/11/25, indicated they reported an allegation of physical abuse that occurred on 05/01/25, involving the Former Director of Nurses (hereby referred to as DON #1) and Certified Nurse Aide (CNA) #1, which included the following: Resident #1 arrived at the Facility at 9:15 A.M. by taxi, carrying only a bag of medications. Resident #1 was unaware of his/her admission to the Facility, having been informed by the Assisted Living Facility he/she was discharged from, that he/she was going on a medical appointment. Upon arrival, Resident #1 appeared agitated due to the unexpected nature of the admission, the realization that he/she would be residing at the Facility, and the bag of medications was taken by a nurse for inventory. Later that afternoon, Nurse #1 observed Resident #1 take pills from a medication bottle that was in his/her pocket, and that Resident #1 told Nurse #1 that they were his/her pain pills and refused to give her the bottle of medication. The Report indicated that when Nurse #1 told Nurse #2 that Resident #1 had taken pain pills from a medication bottle in his/her pocket, she surmised that DON #1 had overheard the exchange. DON #1 then quickly approached Resident #1 and there was a brief physical altercation when she attempted to retrieve the bottle of medication from Resident #1's possession, and that he/she was agitated, uncooperative, and attempted to hit DON #1. DON #1 yelled out to staff call 911 and Nurse #2 responded by telephoning the police. The Report further indicated that DON #1 pried the medication from Resident #1's fingers, that CNA #1 helped hold Resident #1 while she (DON #1) searched his/her pockets, pulling out change and a lighter. DON #1 informed the Substance Use Disorder (SUD) Counselor that Resident #1 had a bottle of prescription medication in his/her possession, and that she was searching for other items. Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, due to his/her combativeness and the staff's inability to determine how many pills he/she had taken. The Report indicated that upon interview, Resident #1 had no recollection of the altercation. Based on the reasonable person concept, it would be more likely than not, that Resident #1 would have experienced psychosocial harm, recurrent fear, anxiety or anger as a result of the unreasonable confinement since there is an expectation that he/she would not be restrained and searched by a provider that had been entrusted to care for him/her. Resident #1 was admitted to the Facility in May of 2025, diagnoses included alcohol dependence with alcohol-induced persisting amnesic disorder (a chronic memory disorder caused by severe deficiency of vitamin B-1), opioid abuse, major depressive disorder and post-traumatic stress disorder. Review of Resident #1's Medical Record indicated that he/she was alert and oriented and could make his/her needs known. Further review of the Record indicated that his/her Health Care Proxy (HCP) was activated prior to admission. During an interview on 05/20/25 at 2:59 P.M., Resident #1 was unable to speak to the events of 05/01/25 and did not have any recollection of the altercation with staff. During a telephone interview on 05/21/25 at 11:22 A.M., Director of Nurses (DON) #1 said that on 05/01/25, Resident #1 had been agitated all morning, and had been yelling and swearing in the hallway because he/she was upset about being tricked into admission to the Facility that morning. DON #1 said that she was called to the first floor at approximately 1:30 P.M. because Resident #1 had a bottle of oxycodone (opioid, used for the treatment of moderate to severe pain) in his/her possession. DON #1 said that when she approached Resident #1, across from the nurses' station, he/she tried to hit her with his/her cane. During a telephone interview on 05/21/25 at 12:45 P.M., Certified Nurse Aide #1 said that on 05/01/25, Resident #1 had been agitated all morning, yelling, swearing and threatening to leave the Facility. CNA#1 said Resident #1 was upset about his/her admission to the Facility. During an interview on 05/20/25 at 2:05 P.M., Nurse #1 said that on 05/01/25 during the early afternoon, Resident #1 approached her medication cart and asked for a cup of water. Nurse #1 said she observed Resident #1 dispense three pills from a prescription medication bottle into the palm of his/her hand. Nurse #1 said that when she asked Resident #1 What have you got there? he/she said that they were his/her pain pills, oxy. Nurse #1 said she asked Resident #1 if she could see the medication bottle and when she reached for it, he/she put the medication bottle back in his/her jacket pocket and said no, they are mine. Nurse #1 said she notified Nurse #2 that Resident #1 had a bottle of pain medication in his/her possession and asked for her help because she wanted to closely monitor Resident #1 until she could reapproach him/her, in attempt to avoid confrontation. Nurse #1 said that DON #1 may have overheard the conversation between herself and Nurse #2, because shortly thereafter, DON #1 appeared suddenly and approached Resident #1 loudly and in a rapid manner, causing the situation to quickly escalate. Nurse #1 said that Resident #1 refused to hand over the medication to DON #1 and verbally threatened to punch someone. Nurse #1 said that DON #1 loudly instructed someone nearby to call 911. Nurse #1 said that at the time of the altercation, Resident #1 was standing in an alcove across from the nurses' station with his/her back against the wall. Nurse #1 said that CNA #1 responded to the situation and positioned himself on Resident #1's left side, while DON #1 was positioned on Resident #1's right side, going through his/her pockets. Nurse #1 said that Resident #1 could not go anywhere because his/her movements were blocked by DON #1 and CNA #1. Nurse #1 said that Resident #1 was yelling and swearing and that DON #1 was responding to him/her with the same level of volume. Nurse #1 said It was out of control, like a street fight. Nurse #1 said the altercation lasted a few minutes. During an interview on 05/20/25 at 2:34 P.M., Nurse #2 said that Nurse #1 notified her that Resident #1 had a bottle of oxycodone in his/her possession and that she (Nurse #1) saw him/her consume two pills from the bottle. Nurse #2 said that she assumed DON #1 overheard her discussion with Nurse #1, because she (DON #1) rushed over to Resident #1 and engaged in a verbal altercation with him/her. Nurse #2 said that when Resident #1 became physical toward DON #1, she (DON #1) yelled, Call 911, and she did as DON #1 directed. Nurse #2 said that there was so much yelling between DON #1 and Resident #1, that the police dispatcher on the other end of the telephone asked who was yelling in the background. Nurse #2 said the altercation between DON #1, CNA #1 and Resident #1 lasted less than five minutes. During a telephone interview on 05/22/25 at 12:01 P.M., Nurse #3 said that she went downstairs to tell DON #1 that Resident #1 had a bottle of oxycodone in his/her possession and would not relinquish it. Nurse #3 said DON #1 went upstairs immediately to address the situation. CNA #1 said he/she was at the nurses' station around 1:30 P.M., when the altercation between DON #1 and Resident #1 began. CNA #1 said that upon seeing Resident #1 lunge toward DON #1, as if he/she was going to hit her, he intervened and positioned himself close to Resident #1's left side, preventing him/her from pulling his/her arm away from the wall. CNA #1 said that when DON #1 tried to get Resident #1 to hand over what he/she was holding, he/she kept his/her hand closed. CNA #1 said that when Resident #1 didn't respond when asked to open his/her hand, he stepped in to block Resident #1's movement and physically pried open his/her hand. During a telephone interview on 05/22/25 at 10:07 A.M., the Finance Assistant said that sometime during the afternoon of 05/01/25, she went upstairs to the unit after hearing a situation was unfolding. The Finance Assistant said she went with the intent to help redirect residents as needed. The Finance Assistant said that from her position at the back of the nurses' station, she observed that DON #1 and CNA #1 held Resident #1 against the wall. The Finance Assistant said that DON #1 was positioned on Resident #1's right side, holding his/her right arm while CNA #1 was on his/her left side, holding his/her left arm. The Finance Assistant said that Resident #1 was yelling, swearing and resisting what was going on. The Finance Assistant said that the altercation lasted less than five minutes. During a telephone interview on 05/22/25 at 10:15 A.M., Certified Nurse Aide (CNA) #3 said that on 05/01/25 at approximately 1:30 P.M., she witnessed Resident #1 being cornered by DON #1 and CNA #1, that Resident #1 had his/her back against the wall in an alcove area across from the nurses' station. CNA #3 said Resident #1 was visibly upset while DON #1 went through his/her pockets, and when he/she refused to open his/her hand. CNA #3 said she heard DON #1 tell CNA #1 to pull back Resident #1's thumb and pry open his/her hand. CNA #3 said CNA #1 held Resident #1's arm, pulled back his/her thumb, and pried open his/her hand. During an interview on 05/20/25 at 1:00 P.M., the Substance Use Disorder (SUD) Counselor said that sometime during the afternoon of 05/01/25, the Social Worker asked him to come inside to assist with a situation involving Resident #1. The SUD Counselor said he observed Resident #1 in the alcove across from the nurses' station with his/her back against the wall. The SUD Counselor said that DON #1 was standing on Resident #1's right side, holding his/her right arm with her left hand, while she used her right hand to go through his/her pockets. The SUD Counselor said that CNA #1 was holding Resident #1 against the wall with his hands on Resident #1's left upper arm. The SUD Counselor said that during the altercation, Resident #1 resisted being held, was visibly upset, and repeated, No! and Leave me alone! The SUD Counselor said the altercation was already underway when he arrived and that he only saw the last 20-30 seconds. The SUD Counselor said the altercation ended after DON #1 pulled a lighter from Resident #1's pocket and then released him/her. Nurse #3 said that she witnessed Resident #1 standing against the wall in an alcove across from the nurses' station. Nurse #3 said that DON #1 was on Resident #1's right side and CNA #1 was on his/her left side, and they each held one of Resident #1's arms. Nurse #3 said she witnessed the altercation for about 30 seconds before it broke up. Nurse #3 said that once the altercation was over, DON #1 went into her office with the items she had found in Resident #1's possession: a bottle of oxycodone, two lighters, and a box of cigarettes. Nurse #3 said she counted the oxycodone with DON #1. During an interview on 05/20/25 at 12:30 P.M., the current Director of Nurses (hereby referred to as DON #2) said that DON #1 was asked to go upstairs to address an issue with Resident #1 and that when she did not come back downstairs, she went to the unit and saw DON #1 walking from the nurses' station to her office. DON #2 said that DON #1 had a bottle of oxycodone, a box of cigarettes and two lighters that had been in Resident #1's possession. DON #2 said she counted the oxycodone with DON #1 and Nurse #3, and that when they could not determine how much of the medication Resident #1 had ingested, the physician gave an order to send him/her to the Hospital Emergency Department to be evaluated. During her interview, DON #1 denied restraining Resident #1 against the wall and denied going through his/her pockets for the bottle of medication. DON #1 said Resident #1 eventually handed over the bottle of medication. DON #1 said she could not recall whether CNA #1 was present during the altercation and did not remember finding two lighters inside a box of cigarettes in Resident #1's possession. During an interview on 05/20/25 at 3:23 P.M., the Administrator said that DON #1 should have cleared the area and attempted to diffuse Resident #1's agitation, monitor him/her closely and reapproach him/her later. The Administrator said that DON #1 and CNA #1 should not have pushed the issue when Resident #1 was agitated. The Administrator said that the outcome of the Facility's internal investigation into the allegations of abuse against DON #1 and CNA #1, was that they did not find their actions to include willful intent. The Administrator said the Facility decided to separate employment with both CNA #1 and DON #1 out of an abundance of caution based on poor customer service.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), and for two of three sampled employees (Certified Nurse Aide #1 and the Substance Use Disorder [SUD] Counselor), the Facility failed to ensure staff implemented and followed their abuse policy related to reporting of abuse allegations and employment requirements. 1) On 05/01/25, although several employees witnessed the Director of Nurses #1 and Certified Nurse Aide #1 physically restrain Resident #1 against the wall while they searched his/her pockets and pried open his/her hand, no one reported the physically abusive altercation immediately to the Administrator or Director of Nurses, who were not made aware until four days later, and 2) prior to working at the facility, a Criminal Offender Record Information (CORI) check was not conducted on Certified Nurse Aide (CNA) #1, and a Massachusetts Nurse Aide Registry (NAR) check was not conducted on the SUD Counselor, as required. Findings include: 1) Review of the Facility Abuse, Neglect and Exploitation Policy, implemented February 2023, indicated it was the policy of the Facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The Policy also indicated that the facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames: -immediately but not later than two hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury or, -not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/11/25, indicated an allegation of physical abuse that occurred on 05/01/25, involving the Former Director of Nurses (hereby referred to as DON #1) and Certified Nurse Aide (CNA) #1, was reported. The Report indicated that during the afternoon of 05/01/25, Nurse #1 observed Resident #1 take pills from a medication bottle that was in his/her pocket. The Report indicated that Resident #1 told Nurse #1 that they were his/her pain pills and refused to give her the bottle of medication. The Report indicated that DON #1 quickly approached Resident #1 and there was a brief physical altercation when she attempted to retrieve the bottle of medication from Resident #1's possession. The Report indicated that Resident #1 was agitated, uncooperative, and attempted to hit DON #1. The Report indicated that DON #1 yelled, call 911 and Nurse #2 responded by telephoning the police. The Report indicated that DON #1 pried the medication from Resident #1's fingers and that CNA #1 helped hold Resident #1 while she (DON #1) searched his/her pockets, pulling out change and a lighter. The Report indicated that DON #1 told the Substance Use Disorder (SUD) Counselor that Resident #1 had a bottle of prescription medication in his/her possession, and that she was searching him/her for other items. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, due to his/her combativeness and the staff's inability to determine how many pills he/she had taken. The Report indicated that upon interview, Resident #1 had no recollection of the altercation. Resident #1 was admitted to the Facility in May of 2025, diagnoses included alcohol dependence with alcohol-induced persisting amnesic disorder (a chronic memory disorder caused by severe deficiency of vitamin B-1), opioid abuse, major depressive disorder and post-traumatic stress disorder. Review of Resident #1's Medical Record indicated that he/she was alert, oriented and could make his/her needs known. Further review of the Record indicated that his/her Health Care Proxy (HCP) was activated prior to admission. During an interview on 05/20/25 at 1:00 P.M., the Substance Use Disorder (SUD) Counselor said that sometime during the afternoon of 05/01/25, the Social Worker asked him to come inside to assist with a situation involving Resident #1. The SUD Counselor said he observed Resident #1 in the alcove across from the nurses' station with his/her back against the wall. The SUD Counselor said that DON #1 was standing on Resident #1's right side, holding his/her right arm with her left hand, while she used her right hand to go through Resident #1's pockets. The SUD Counselor said that CNA #1 was holding Resident #1 against the wall with his hands on his/her left upper arm. The SUD Counselor said that during the altercation, Resident #1 resisted being held, was visibly upset, and repeated No! and Leave me alone! The SUD Counselor said the altercation was already underway when he arrived and that he only saw the last 20-30 seconds. The SUD Counselor said the altercation ended after DON #1 pulled a lighter from Resident #1's pocket and then they (DON #1 and CNA #1) released him/her. The SUD Counselor said that several other employees had witnessed the altercation as well. The SUD Counselor said he did not report the abuse allegation until 05/05/25, four days later, and that he should have reported it immediately to the Administrator. During an interview on 05/20/25 at 3:23 P.M., the Administrator said that although he was notified on 05/01/25 that Resident #1 had a bottle of oxycodone in his/her possession and was sent out to the ED for evaluation, he was unaware of the allegation of abuse involving DON #1 and CNA #1, until it was reported to him on 05/05/25 by the SUD Counselor. The Administrator said the allegation of abuse should have been reported immediately. 2) Review of the Facility Abuse, Neglect and Exploitation Policy, implemented February 2023, indicated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The Policy further indicated that background reference and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The Policy indicated the facility will maintain documentation of proof that the screening occurred. Review of CNA #1's Employee File indicated his first date of employment at the Facility was on 02/10/25. Further review of CNA #1's Employee File indicated a CORI check was not obtained until 04/23/25, over two months after CNA #1 started working at the Facility. There was no documentation to support that a CORI check had been conducted prior to his employment at the Facility. Review of the SUD Counselor's Employee File indicated his first date of employment at the Facility was on 10/07/24. Further review of the SUD Counselor's Employee File indicated that there was no documentation to support that a Massachusetts NAR check had been conducted prior to his employment at the Facility. The Administrator said the Facility had no documentation to support that an NAR check had been conducted for the SUD Counselor or that a CORI check had been conducted on CNA #1, before they started working at the Facility. The Administrator said that CORI checks and NAR checks should be run on all employees prior to working at the Facility.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that on 05/05/25, after Facility Administration was made aware of an allegation of physical abuse of a resident (Resident #1) by Director of Nurses (DON) #1 and Certified Nurse Aide (CNA) #1, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 05/11/25, (six days later). Findings include: Review of the Facility's Policy titled, Abuse, Neglect and Exploitation, dated as revised February 2023, indicated reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: -Immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or -Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 05/11/25, indicated an allegation of physical abuse occurred on 05/01/25, involving the Former Director of Nurses (hereby referred to as DON #1) and Certified Nurse Aide (CNA) #1. The Report indicated that during the afternoon of 05/01/25, Nurse #1 observed Resident #1 take pills from a medication bottle that was in his/her pocket. The Report indicated that Resident #1 told Nurse #1 that they were his/her pain pills and refused to give her the bottle of medication. The Report indicated that DON #1 quickly approached Resident #1 and there was a brief physical altercation when she attempted to retrieve the bottle of medication from Resident #1's possession. The Report indicated that Resident #1 was agitated, uncooperative, and attempted to hit DON #1. The Report indicated that DON #1 yelled, call 911 and Nurse #2 responded by telephoning the police. The Report indicated that DON #1 pried the medication from Resident #1's fingers and that CNA #1 helped hold Resident #1 while she (DON #1) searched his/her pockets, pulling out change and a lighter. The Report indicated that DON #1 told the Substance Use Disorder (SUD) Counselor that Resident #1 had a bottle of prescription medication in his/her possession, and that she was searching him/her for other items. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, due to his/her combativeness and the staff's inability to determine how many pills he/she had taken. The Report indicated that upon interview, Resident #1 had no recollection of the altercation. Review of a Written Report, dated 05/05/25, given to the Administrator by the SUD Counselor, alleged that on 05/01/25, DON #1 and Certified Nurse Aide (CNA) #1 held Resident #1 against the wall by his/her arms, searched him/her, then removed coins and a lighter from his/her pockets. The Report alleged that DON #1 said that Resident #1 had a bottle of prescription medicine in his/her pocket and that she was also searching for other items. Resident #1 was admitted to the Facility in May of 2025, diagnoses included alcohol dependence with alcohol-induced persisting amnesic disorder (a chronic memory disorder caused by severe deficiency of vitamin B-1, opioid abuse, major depressive disorder, recurrent, and post-traumatic stress disorder. Review of Resident #1's Medical Record indicated that he/she was alert and oriented and could make his/her needs known. Further review of the Record indicated that his/her Health Care Proxy (HCP) was activated prior to admission. During an interview on 05/20/25 at 1:00 P.M., the Substance Use Disorder (SUD) Counselor said that on the morning of 05/05/25, he reported an allegation of physical abuse involving Resident #1 to the Administrator, that occurred on 05/01/25 during an altercation with DON #1 and CNA #1. The SUD Counselor said he reported the allegation both verbally and in writing. During an interview on 05/20/25, the Administrator said he was unsure why the allegation of physical abuse was not submitted to DPH within the required two hours. The Administrator said he would need to verify when the current Director of Nurses (hereby referred to as DON #2) reported the physical abuse allegation via HCFRS. During an interview on 05/20/25 at 4:20 P.M., DON #2 said that she started to report the abuse allegation on 05/05/25 to DPH via HCFRS, but did not submit the information until 05/11/25 because she misunderstood and thought she had five days to submit the allegation.

Based on record review and interview, the facility failed to review and revise the plan of care pertaining to urinary catheter care and services for one Resident (#30) out of a total sample of 16 residents. Specifically, the facility failed to review and revise the plan of care when Resident #30's indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) was changed in the hospital from a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) to an indwelling urinary catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag). Findings include: Resident #30 was admitted to the facility in September 2018, with a diagnosis of Neuromuscular Dysfunction of the Bladder (a condition where the nerves and muscles of the bladder do not work together well and can cause problems with the emptying of the bladder). Review of Resident #30's medical record indicated that a care plan, initiated on 7/23/24, was created for the use of a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) because of neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly). Further review of the medical record indicated the care plan was last revised on 7/24/24. Review of Nursing Progress Note dated 8/27/24, indicated Resident #30 returned from the hospital ER (emergency room ), was unsuccessful in reinserting a new suprapubic catheter and an indwelling urethral Foley [brand name of the catheter] catheter was placed. Review of Nursing Progress Note dated 10/1/24, indicated the facility staff received a call from the hospital stating the hospital staff replaced the indwelling urethral Foley catheter with an 18 Fr (French -size of urinary catheter). Review of Resident #30's October 2024 Physician's orders indicated the following Foley catheter orders initiated on 8/28/24: -Foley catheter care every shift -Foley catheter to bedside for drainage -Irrigate Foley catheter as needed . -Replace Foley catheter as needed Further review of the October 2024 Physician's orders did not indicate what size Foley catheter/ balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) was in place for Resident #30. During an interview on 10/7/24 at 2:15 P.M., the surveyor, the Assistant Director or Nursing (ADON), and the Director of Nursing (DON) reviewed the October 2024 Physician orders and the care plans for Resident #30. The DON said that the Foley catheter size should be written on the Physician orders but was not. The DON said that the care plans should have been updated in August, when the Resident returned from the hospital and the suprapubic catheter was replaced with an indwelling urinary Foley catheter, but the care plans had not been updated as required.

Based on record review, and interview, the facility failed to provide care in accordance with professional standards of practice related to Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) care for one Resident (#24) out of a total sample of 16 residents. Specifically, for Resident #24, the facility failed to ensure that the Physician orders which indicated agreement with the Hospice recommendations for scheduled pain and anxiety management were implemented and the care plan followed for appropriate pain management and symptom control resulting in the Resident requiring frequent pain and anxiety medication administration for pain and symptom management. Findings include: Review of the facility's policy titled Comfort Measures dated April 2015, indicated the following: -The care plan will include interventions developed to promote pain management and to address the actual and/or potential physical/emotional/spiritual comfort needs of the resident/patient. Resident #24 was admitted to the facility in January 2024, with Vascular Dementia (brain damage from impaired blood flow to the brain caused by multiple strokes leading to memory loss and difficulty with reasoning, planning, judgment and other thought processes). Review of the Resident's most recent Minimum Date Set (MDS) assessment, dated 8/20/24, indicated: -the Resident had severe cognitive impairment as evidenced by the Brief Interview of Mental Status (BIMS) score of zero out of a possible 15 points. -the Resident was dependent on staff for all activities of daily living (ADL). -the Resident was receiving Hospice Care Services. Review of the Nurses Progress Note, dated 8/14/24, indicated the Resident was admitted to Hospice Services. Review of the Hospice Care Narrative Notes, dated 8/28/24, indicated the following recommendations: -Schedule Morphine (pain medication used to treat moderate to severe pain) 0.25 milliliters (ml) PO (orally)/SL (sublingual-under the tongue) twice daily. -Schedule Lorazepam (Ativan - medication used to treat anxiety) 0.5 milligrams (mg) PO/SL twice daily. -PRN (as needed) orders for Morphine and Lorazepam will stay the same. Further review of the Hospice Care Narrative Notes, dated 8/28/24, indicated a circled initial at the bottom of the Hospice Care Narrative Note. Review of the Nurses Progress Notes dated 8/28/24 through 10/3/24, showed no evidence to indicate the Hospice recommendations from 8/28/24 had been reviewed, accepted or declined, and showed no evidence of the Resident's current Hospice plan of care. Review of the current Physician's orders dated 10/3/24, indicated the following: -Hospice evaluation when approved by Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions), dated 8/1/24. -Morphine Sulfate oral solution 20 mg/ml, give 0.25 ml by mouth every four hours as needed (PRN) for mild to moderate pain/shortness of breath, date initiated 8/14/24. -Morphine Sulfate oral solution 20 mg/ml, give 0.5 ml by mouth every four hours as needed (PRN) for severe pain/shortness of breath, date initiated 8/14/24. -Lorazepam oral tablet 0.5 mg, give one tablet by mouth every four hours as needed (PRN) for mild to moderate anxiety/agitation/restlessness, date initiated 8/14/24. - Lorazepam oral tablet 0.5mg, give two tablets by mouth every four hours as needed (PRN) for severe anxiety/agitation/restlessness, date initiated 8/14/24. Further review of the Physician's orders dated 10/3/24 (total of 36 days since the Hospice recommendations were made on 8/28/24), showed no evidence that the Hospice recommendations dated 8/28/24, to schedule Morphine 0.25 ml/5 mg and Ativan 0.5 mg twice daily had been implemented. Review of the August 2024 Medication Administration Record (MAR) indicated the Resident received Morphine 0.25 ml by mouth, for mild to moderate pain, as needed (PRN) with effect on the following days/times: 8/28/24: -at 4:11 A.M. for a pain score of 9 out of ten -at 11:04 P.M. for a pain score of eight out of ten 8/31/24: -at 2:13 A.M. for a pain score of six out of ten -at 7:56 P.M. for a pain score of five out of ten Review of the August 2024 MAR also indicated that the Resident received Lorazepam 0.5 mg, two tablets as needed (PRN) for severe anxiety/agitation/restlessness with effect on the following days/times: >8/18/24 at 8:30 AM >8/21/24 at 5:23 PM Further review of the August 2024 MAR indicated the Resident received Lorazepam 0.5 mg, one tablet as needed (PRN), for mild to moderate anxiety/agitation/restlessness with effect on the following days/times: >8/28/24: -at 5:15 P.M. >8/31/24: -at 2:13 A.M -at 7:56 P.M. Further review of the August 2024 MAR showed no evidence that the Hospice recommendations dated 8/28/24, to schedule Morphine 0.25 ml/5 mg and Ativan 0.5 mg twice daily had been implemented. Review of the September 2024 MAR indicated the Resident received Morphine 0.25 ml by mouth, as needed (PRN) for mild to moderate pain with effect on the following days/times: >9/4/24: -at 6:35 A.M. for a pain score of eight out of ten >9/11/24: -at 4:12 A.M. for a pain score of 8 out of ten >9/13/24: at 12:30 A.M. for a pain score of 6 out of ten Further review of the September 2024 MAR indicated the Resident received Morphine 0.5 ml by mouth, as needed (PRN) for severe pain with effect on the following days/times: >9/2/24: -at 2:07 A.M. and 11:35 P.M. for a pain score of seven out of ten -at 11:25 P.M. for a pain score of six out of ten >9/3/24: -at 11:21 P.M. for a pain score of six out of ten >9/5/24: -at 4:45 A.M. for a pain score of seven out of ten -at 11:43 P.M. for a pain score of six out of ten >9/7/24: -at 4:30 A.M. for a pain score of eight out of ten >9/10/24: -at 4:14 A.M. for a pain score of seven out of ten >9/12/24: -at 3:31 A.M. for a pain score of seven out of ten -at 10:00 P.M. for a pain score of five out of ten >9/15/24: -at 5:25 P.M. for a pain score of six out of ten -at 11:49 P.M. for a pain score of eight out of ten >9/19/24: -at 7:07 A.M. for a pain score of eight out of ten >9/20/24: -at 8:21 A.M. for a pain score of nine out of ten >9/23/24: -12:00 A.M. and 4:00 A.M. for a pain score of seven out of ten >9/24/24: -at 4:36 A.M. for a pain score of seven out of ten >9/26/24: -at 1:00 A.M. for a pain score of seven out of ten >9/27/24: -at 12:05 A.M. for a pain score of seven out of ten >9/28/24: -at 1:43 A.M. for a pain score of five out of ten >9/29/24: -at 12:10 A.M. for a pain score of seven out of ten -at 4:48 P.M. for a pain score of six out of ten >9/30/24: -at 12:13 A.M. for a pain score of seven out of ten Further review of the September 2024 MAR indicated the Resident received Lorazepam 0.5 mg, one tablet as needed (PRN), for mild to moderate anxiety/agitation/restlessness with effect on the following days/times: >9/2/24: -at 2:07 A.M. >9/3/24: -at 11:21 P.M. >9/5/24: -at 4:45 A.M. >9/7/24: -at 4:40 A.M. >9/10/24: -at 4:15 A.M. and 5:16 P.M. >9/12/24: -at 1:43 A.M. and 11:37 P.M. >9/14/24: at 4:17 A.M. >9/15/24: at 5:24 P.M. >9/19/23: at 9:01 A.M. >9/22/24: at 8:02 A.M. >9/24/24: at 4:35 A.M. Review of the September 2024 MAR indicated the Resident received Lorazepam 0.5mg, two tablets as needed (PRN) for severe anxiety/agitation/restlessness with effect on the following days/times: >9/11/24: -at 4:58 A.M. >9/13/24: -at 12:00 A.M. >9/16/24: -at 12:28 A.M. >9/22/24: -at 12:44 P.M. >9/30/24: -at 12:12 A.M. Further review of the September 2024 MAR showed no evidence that the Hospice recommendations, dated 8/28/24, to schedule Morphine 0.25 ml/5 mg and Ativan 0.5 mg twice daily had been implemented. Review of the MAR dated 10/1/24 and 10/2/24 indicated the Resident received Morphine 0.5 ml by mouth, as needed (PRN) for severe pain with effect on the following days/times: >10/1/24: -at 2:17 A.M. for a pain score of six out of ten >10/2/24: -at 2:10 A.M. for a pain score of seven out of ten Further review of the MAR, dated 10/1/24 and 10/2/24, showed no evidence that the Hospice recommendations, dated 8/28/24, to schedule Morphine 0.25 ml/5 mg and Ativan 0.5 mg twice daily had been implemented. Review of the Resident's Care Plan dated 10/3/24, showed no documented evidence that a Hospice care plan was part of the medical record. During an interview on 10/3/24 at 8:45 A.M., the MDS Nurse said she was unable to find a Hospice Care Plan for the Resident. The MDS Nurse further said that she should have initiated a Hospice care plan in the portion maintained by the facility after the significant change assessment had been completed on 8/20/24. The MDS Nurse said that once she sees there is an order for Hospice, she schedules an MDS assessment and an Interdisciplinary Team (IDT) meeting. The MDS Nurse said that she should have created a Hospice Care Plan at that time, but she did not. During an interview on 10/3/24 at 9:08 A.M., the surveyor and the Staff Development Coordinator (SDC) reviewed the Hospice Narrative Note dated 8/28/24. The SDC said the circled initial on the bottom of the Hospice Narrative Note indicated that the Provider (Physician) had reviewed and approved the Hospice recommendations to schedule Morphine and Lorazepam twice a day. The SDC said that she was not sure why the orders had not been entered into the electronic medical record (EMR). The SDC said that she would check with the Director of Nursing (DON). The SDC said the process for new Hospice recommendations is that the Hospice Nurse writes the recommendations and gives them to the facility Nurse, the facility Nurse then gives the recommendations to, or calls the Provider and if the Provider approved, enters the new orders into the EMR. During an interview on 10/3/24 at 10:06 A.M., the DON said that she or the Assistant Director of Nursing (ADON) are the facility contact staff for collaborating with the Hospice Provider. The DON said that she reached out to Hospice today to try to figure out what went wrong with the facility system. The DON said that the Hospice Nurse comes to the facility every week and should have noticed that the recommendations from 8/28/24 had not been started. The DON further said the Hospice recommendations should have been initiated as soon as they had been approved by the Provider, but that they had not been initiated until today.

Based on observation, interview, record and policy review, the facility failed to provide respiratory care and services based on professional standards of practice, for one Resident (#22) out of a total sample of 16 residents. Specifically, for Resident #22, the facility failed to: 1. Change the oxygen tubing as ordered by the Physician. 2. Follow infection control measures related to the care, handling, and/or storage, by ensuring the Resident's oxygen tubing was maintained off the floor and stored in a clean storage bag. Findings include: Review of the facility's Nursing Policy and Procedure Manual (Oxygen Administration Nasal Cannula) last revised November 2020, indicated the following: -Replace and date cannula and tubing weekly or when visibly soiled or damaged . - .The nasal cannula will be stored in a plastic bag and maintained off the floor. Resident #22 was admitted to the facility in January 2024, with diagnoses including shortness of breath, dependence on supplemental Oxygen, and Emphysema (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath) Review of the October 2024 Physician orders indicated the following: -Oxygen (O2) via two liters per minute (2 LPM) nasal cannula (n/c - a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) (order date 1/22/24) -Change O2 tubing every Sunday on 11-7 shift (order date 1/22/24) Review of the Resident #22's September 2024 Treatment Administration Record (TAR) indicated the oxygen tubing was changed on 9/29/24 during the 11-7 shift, signed off with a check mark and the Nurses' initials. On 10/2/24 at 9:29 A.M., the surveyor observed Resident #22 lying in bed with his/her head covered with blankets, with the oxygen tubing and nasal cannula on the floor under the Resident's bed. The surveyor observed that the oxygen tubing was dated 9/23/24. On 10/3/24 at 10:30 A.M., the surveyor observed Resident #22 sleeping in bed with the oxygen tubing and nasal cannula on the floor. The surveyor observed that the oxygen tubing was dated 9/23/24. During an interview on 10/3/24 at 11:00 A.M., Nurse #1 said that the Resident had an order for continuous oxygen, however he/she would frequently take the Oxygen off. Nurse #1 said that the Resident required frequent reminders to put the Oxygen back on. The surveyor and Nurse #1 reviewed the October 2024 Physician orders and the September 2024 TAR for Resident #22. Nurse #1 said that it appeared the oxygen tubing was last changed on 9/29/24 as it had been checked off and initialed by the Nurse. On 10/3/24 at 11:06 A.M., immediately following the interview, the surveyor and Nurse #1 observed the following in Resident #22's room: -Resident lying in bed sleeping, not wearing Oxygen. -Oxygen tubing was on the floor next to the Resident's bed. -Oxygen tubing was dated 9/23/24, not 9/29/24 as indicated on the TAR. -Portable oxygen tank, located on the Resident's wheelchair, was on and running. -The oxygen tubing and nasal cannula attached to the portable oxygen tank was on the floor underneath the wheelchair. -No plastic oxygen storage bags were visible in the Resident's room. Nurse #1 said that the oxygen tubing from the (stationary) oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated to the individual) and the portable oxygen tank should not be on the floor. Nurse #1 said that when the n/c was not in use, the n/c and oxygen tubing should be stored in a plastic bag, not on the floor. Nurse #1 said that there was not a plastic bag available in the Resident's room to store the unused oxygen tubing. Nurse #1 said that the date on the oxygen tubing did not reflect what had been signed off on the TAR and that the oxygen tubing had not been changed weekly as ordered.

Based on interview, and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#18) out of a total sample of 16 residents. Specifically, for Resident #18, the facility failed to ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post Traumatic Stress Disorder (PTSD- a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares, and severe anxiety). Findings include: Review of the facility policy titled Trauma Informed Care Policy and Procedure, undated, indicated a trauma informed care plan will be documented in the Resident's medical record by Social Services in conjunction with the IDT (Interdisciplinary Team). Resident #25 was admitted to the facility in September 2022, with diagnoses including PTSD, Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), Alcohol Dependence, and Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of Resident #25's medical record indicated no documented evidence that a comprehensive care plan had been developed for Resident #18 relative to the Resident's history of PTSD. During an interview on 10/7/24 at 3:29 P.M., Social Worker (SW) #2 said that an initial baseline care plan should be completed upon admission and if a Resident had a diagnosis of PTSD, it would be noted on the mood care plan. SW #2 said that if a Resident had active symptoms of PTSD the staff would then create a specific care plan relative to PTSD. SW #2 said that Resident #18 does have a diagnosis of PTSD and it would most likely be noted on a mood care plan. The surveyor, SW #1, and SW #2, reviewed Resident #18's care plans and did not find a care plan that referenced a history of PTSD, possible triggers, or any individualized interventions.

Based on record, policy review, observations and interview, facility staff failed to ensure a comprehensive care plan had been developed/implemented for 1 sampled Residents (#15) from a total of 15 sampled residents. Findings include: For Resident #15, facility staff failed to ensure the care plan had been developed/implemented, with effective interventions related to falls, and for a clip seat belt device, which the facility staff identified was being used for positioning. Resident #15 was admitted to the facility in 7/2015. The resident's [DIAGNOSES REDACTED]. A. Review of the facility's policy entitled Falls Management, (revised 8/2018), indicated the following: - The facility will utilize all resident related information made available upon admission and ongoing to determine resident at-risk for fall status. - The Interdisciplinary Team (IDT) will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. Review of the updated care plan, 6/12/17 - 9/2017, related to falls, and a self care deficit, included interventions as follows: - Requires assistance for bed mobility, and 2 staff assist for use of a walker and toileting. Do not leave resident alone in the bathroom. Offer resident toileting, upon rising, before and after meals and activities and before bed. - Gather, provide, equipment needed. Make sure equipment is functioning properly. Review of a progress note, and investigation report, dated 7/7/18, indicated at 5:15 P.M., Resident #15 was forgetful and confused. The resident was in his/her bedroom, sitting up in a stationary chair, awaiting the evening meal, and fell trying to get up from the chair to go to the bathroom. The confused and forgetful resident had been told to call for assistance, if needed. The resident had received a diuretic medication, prior to 5:15 P.M., a medication which increases the urge to urinate, and is prescribed to excrete excess fluid. The resident fell , was sent to the hospital, and was diagnosed with [REDACTED]. Review of a progress note, dated 7/19/18, indicated the resident fell at 8:20 A.M., and was sent to the hospital. The resident was re-oriented to the call light, and to call for help when needed. (Ineffective intervention, as the resident has dementia, and is confused and forgetful.) Review of the Fall Assessment, updated 7/2018, continued to identify the resident as being a high risk for falls. A Significant Change in Condition Minimum Data Set (MDS) Assessment, dated 7/26/18, identified the resident had a decline in Activities of Daily Living (ADLs), and required extensive assist with ADLs, transfers, did not walk in room or corridor and used a wheelchair (w/c) for mobility. Review of a progress note and investigation report, dated 8/24/18, indicated the resident fell in the bathroom at 3:10 P.M., and sustained an abrasion to the right thigh, requiring a treatment. An X-Ray was obtained, and a fracture was ruled out. The investigation report indicated the resident had toileted self, then fell while attempting to transfer self back into the w/c. The w/c was observed tipped over on its side. The left w/c leg rest was off, and found under the resident's right buttock. The fall was not witnessed. The report identified Resident #15 was unsteady, received a diuretic medication, the call light was not in reach, was still recovering from a recent [MEDICAL CONDITION], and had been observed by staff 10 minutes prior to the fall in the resident's room. The care plan had not been followed when staff did not assist the resident to the bathroom, and did not ensure the call light was in reach, as the facility identified it should be, and the resident required re-orienting for use of the light after the 7/19/18 fall. The care plan was updated 8/24/18 and included the following interventions: educate the resident to call for assistance with all transfers and toileting, and provide assist of two for toileting with use of a rolling walker. Review of the Quarterly MDS Assessment, dated 10/25/18, indicated the resident continued to require extensive assistance for transfers, toileting and used a w/c for mobility. Review of the progress note and investigation report, dated 11/19/18 at 4:45 P.M., indicated the resident was found on the floor in the bathroom, next to the toilet, with urine soaked pants. The fall was not witnessed. The resident sustained [REDACTED]. The resident did not call for help, although the call light was within reach. The care plan was not followed for Resident #15, who was at a high risk for falls, required 2 assists for transfers, toileting, and was supposed to be toileted before meals. B. Review of the Facility's policy entitled: Positioning and Body Alignment, dated 4/2015, indicated the following: - Each Resident who is partially or totally dependent is positioned in good body alignment at all times. - Place buttocks as far back in the chair/wheelchair as possible. For Resident #15 facility staff failed to develop and implement a comprehensive and individualized care plan for use of a seat belt. Review of Resident #15's care plan for self care deficit, related to muscle weakness, and forgetfulness secondary to dementia, indicated an intervention to use a seat belt for sacral sitting (updated 11/1/18). There was nothing else documented regarding use of the seat belt, whether to use it only in a w/c, or for use in any chair to prevent sacral sitting, when to reposition the resident for pressure relief, when to release it, or ensure the resident could release it at scheduled or unscheduled intervals to ensure the seat belt was not a restraint device, etc., for this resident who the facility identified was cognitively impaired with dementia. The care plan did not include ensuring the resident had been positioned in good body alignment at all times, or ensure the resident's buttocks were as far back in the w/c as possible, in accordance with the facility's policy. Review of the resident's care plan related to risk for aspiration and weight loss (dated 8/5/15), indicated staff were to ensure the resident ate meals in an upright position. On 1/10/19 at 9:52 A.M., the surveyor observed Resident #15 sitting in a w/c with a clip belt device fastened around the resident's waist. The resident was sitting in a slouched position (considered sacral sitting, whereby, buttocks are not seated back in the chair, and considered poor seat posture). The resident's feet where propped on foot rests. The w/c design did not allow the resident to sit properly, with buttocks squarely back on the seat, and was too small for this resident. The surveyor asked Resident #15 if he/she could release the seat belt. The resident said he/she could, but the last time he/she tried, staff got mad .so I can't touch it again. On 1/14/19 at 10:16 A.M., Resident #15 attended the group meeting with the surveyors. The resident was seated in a w/c with a seat belt secured about the waist. The resident was sitting in a slouched, sacral sitting position, and not with buttocks squarely back on the seat. On 1/14/19 at 11:50 A.M., the surveyor observed Resident #15 sitting in a w/c, up to a table in the Dining Room, with the clip seat belt secured around the waist. The resident was sitting in a slouched/sacral sitting position, and not sitting upright, with buttocks squarely back on the seat. No staff attempted to reposition the resident to ensure the resident was sitting correctly, at all times, in accordance with the facility's policy. On 1/15/19 at 5:10 P.M., the surveyor observed Resident #15 sitting in a w/c up to a table in the Dining Room, with a clip belt secured around the waist. The resident was sitting with in a slouched/sacral sitting position. The w/c was alongside the table, rather than up to the table, as he/she reached over for beverages to drink. Although staff were present, no staff attempted to reposition the resident to ensure the resident was sitting correctly, at all times, in accordance with the facility's policy. During interview on 1/16/19 at 11:12 A.M., Certified Nursing Assistant (CNA) #1 said she was very familiar with Resident #15, and was assigned to this resident's care today. The surveyor asked CNA #1 as to why Resident #15 was wearing a seat belt. CNA #1 said for safety. The surveyor asked CNA #1 what safety measures the belt had been intended for. CNA #1 said, I have to put the belt on the second the resident gets out of bed and goes in the wheelchair. CNA #1 said that she takes it off when the resident goes to the bathroom, but the belt has to go back on. The surveyor asked CNA #1 about a care plan for the seat belt. CNA #1 said she would have to look at the resident's care card, and instructions should be on the care card. Review of Resident #15's care card, indicated it was last updated 10/16/18, and did not include any information related to use of the seat belt, whether for positioning, safety, or what the intended use was, in order for CNAs to properly care for this resident, and ensure proper positioning. CNA #1 reviewed the front and back of the resident's care card/plan, and said there was nothing on the care card related to use of the seat belt device, and she would have to ask nursing why the seat belt was being used. Review of an Occupational Therapy (OT) note, dated 10/31/18, indicated that OT screened the resident for positioning in a w/c, using a positioning belt. Review of an OT note, dated 11/26/18, indicated OT was trialing a new w/c cushion to improve positioning in the w/c, and the resident was noted to slide less, however, continued to require pelvic positioning belt and demonstrated poor posture. During interview on 1/16/19 at 11:54 A.M., the Director of Rehabilitation (Rehab) said she was the OT who had treating Resident #15, and recommended use of the seat belt for positioning. The Director said the resident does not sit correctly in the current w/c, and a special w/c had been ordered on [DATE]. The Director said they are still waiting for the new chair to come and it takes about 4 - 6 weeks. The Director said the clip belt was implemented to prevent the resident from sacral sitting, and sliding down in the wheelchair. The surveyor pointed out that Resident #15 was still sacral sitting in a slouched posture, even with the seat belt attached, and no staff ensured the resident sat correctly in the w/c in accordance with the facility's policy. The Director said that Resident #15's sitting was far better with the belt than without it. She said the resident is not currently on case load. The Director said that she did recall speaking to staff about use of the seat belt back in 10/2018 for positioning, but did not develop a care plan for use of the belt, such as when and under what circumstances to remove the belt, a physician's orders [REDACTED]. The Director said she thought nursing would have developed a care plan for use of the belt, and instruct the resident on adjusting his/her posture when slouching, by asking the resident to scoot back, or by staff assist, depending on the time of day and when the resident may be fatigued. The Director said she should have written down pertinent information and education provided to staff, and did not. She said instructions and education were verbal discussions. Please refer to F684.

Based on observation, record, policy review and interview, facility staff failed to ensure 1 sampled Residents (#15), from a total sample of 15 residents received adequate supervision and effective interventions to prevent accidents related to falls. Findings include: Review of the facility's policy entitled: Falls Management (revised 8/2018) indicated the following: - The facility will utilize all resident related information made available upon admission and ongoing to determine resident at-risk for fall status. - The Interdisciplinary Team (IDT) will develop initiate and implement an appropriate individualized care plan based on the fall risk evaluation score. - Residents who are identified to be at risk will have a safety related care plan developed. For Resident #15, admitted to the facility in 7/2015, with [DIAGNOSES REDACTED]. Review of the at risk for falls care plan, initiated 8/5/15, indicated the resident was at a high risk for falling due to previous falls, generalized weakness, and cognitive impairment. The Interventions section of the falls care plan indicated the resident has had several falls; is to wear gripper socks at all times; educate resident on proper way to wear gripper socks. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/26/17, indicated the resident had moderately impaired cognitive abilities; expressed feeling down, depressed, tired, with little energy; had behaviors, such as delusions with verbal threats toward others; Activities of Daily Living (ADLs) indicated the resident required supervision for bed mobility, transfers, walking in room and corridor, as well as locomotion on and off the unit, eating, toilet use, hygiene, bathing; required limited assist from staff for dressing; had balance problems; no range of motion problems; used a walker for mobility; was frequently incontinent of bladder; had no infections; coded as having non-Alzheimer's dementia; depression, [MEDICAL CONDITION]; [MEDICAL CONDITIONS]; used as needed (PRN) pain medications; had no falls; and received 7 days of antipsychotic, antianxiety, antidepressant and diuretic medications. Review of the clinical record indicated in progress notes, dated 11/12 and 11/17/17, that Resident #15 had an upper respiratory infection (URI) requiring an antibiotic, and oxygen (O2). The resident also had a rash to the left leg, identified as being [MEDICAL CONDITION], also requiring an antibiotic. Review of a progress note, dated 11/24/17, indicated the resident was found on the floor, beside the bed. The investigation report surrounding the 11/24/17 fall, indicated the resident said he/she slipped off the bed. There were no injuries associated with this fall. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 1/25/18, indicated the resident was moderately impaired for cognitive abilities; required supervision for bed mobility, transfers, walking in room and corridor, toilet use, had problems with balance, and used a walker. Review of the Quarterly MDS Assessment, dated 4/26/18, indicated the resident's cognitive abilities and Activities of Daily Living (ADLs) were essentially unchanged, and the resident had no falls. Review of a progress note, dated 7/3/18, indicated Resident #15 was acutely ill with an O2 saturation level of 73 % (considered very low), with respiratory problems, was sent to the hospital and was admitted with pneumonia. Review of a progress note, dated 7/7/18 at 3:00 P.M., indicated the resident returned back to the facility, required oxygen (O2), had labored breathing, required a nebulizer breathing treatment, was incontinent of urine and loose stools upon arrival to facility, and was confused as to the date and time, and had poor mobility since the hospital stay. The resident required a mechanical lift to transfer for safety. The note indicated Resident #15 was transferred into a bedside chair for the evening meal, and continued on an antibiotic for pneumonia. Review of a progress note, dated 7/7/18 at 5:15 P.M., indicated the resident was found on floor in the resident's room. The resident could not move his/her right leg without discomfort. Review of the investigation report surrounding the 7/7/18 fall, indicated the fall was not witnessed. The report indicated the resident had received a diuretic (medication used to remove excess water from the body), and was awaiting his/her meal, sitting in a stationary chair, when the resident apparently got up to go to the bathroom to urinate, and fell . The resident was found on the floor between Bed A and Bed B in the resident's room. The report documented the determining factor for this fall contributed to the resident being up alone, and should have had assistance, due to a recent hospitalization , increased weakness, decline in function, a history of falling, dementia and depression. Review of a fall risk assessment, dated 7/7/18, continued to identify the resident as being at a high risk for falling, due to confusion; 1-2 falls in the past month; incontinence; balance problems standing, while walking, decreased muscular coordination; jerking or unstable when making turns, and receives diuretics, antibiotics, antipsychotic, antidepressant, antihypertensive and benzodiazepine medications. Review of a progress note, dated 7/17/18, indicated the resident returned back to facility from the hospital, and had required surgery to repair the fractured right hip. The resident had 16 staples to the incision sites. The resident's right elbow laceration also had 2 sutures, as a result of the fall, and the resident was identified as being weak. Review of a progress note, dated 7/19/18, indicated the resident fell , was sent to the hospital for an evaluation, and returned back to the facility, later the same day. The resident was educated regarding keeping both legs on the bed, and to use the call light for help when needed. Review of the investigation surrounding the 7/19/18 fall, indicated the fall was not witnessed, the resident was wearing non-skid slippers, and fell while trying to get out of bed. The resident required assistance via a mechanical lift to get off the floor. The report indicated the resident had just returned from the hospital after fracturing his/her hip. There were no injuries as a result of this fall. Interventions put in place to prevent further falls were: Encourage resident to call for assistance, for this resident with confusion, forgetfulness, weakness, required extensive assist for bed mobility and transfers, and historically does not use the call light to ask for help, when needed. Review of the 7/26/18 Significant Change in Condition MDS Assessment, indicated the resident had impaired cognitive abilities, a decline in ADLs, requiring extensive assist with bed mobility, transfers, now, did not walk in room or corridor, used a wheelchair (w/c), had problems with balance, a [MEDICAL CONDITION], one fall with no injury, and inaccurately coded the resident did not have a fall with major injury (fall with [MEDICAL CONDITION] and laceration requiring sutures to the right elbow) in Section J to accurately address falls. The resident received 7 days of antipsychotic, antidepressant and diuretic medications. Review of the Care Area Assessment (CAA) related to falls indicated the following: - Resident has balance problems, moving from a seated to a standing position, and only able to stabilize with staff assistance with moving on and off toilet, and surface to surface transfer. - Resident receives antidepressant medications. - Resident is at risk for falls related to (r/t) recent [MEDICAL CONDITION] (fx) with surgical repair, potential for pain, staff assistance for all transfers, recent falls, and medications that can affect balance. - Difficulty maintaining sitting balance. - Antipsychotic, antidepressants and diuretic medications. - Medical Diagnoses: [REDACTED]. A decision was made to proceed with a care plan. Review of the updated falls care plan, after the 7/2018 fall, indicated for staff to place mats on left and right sides of the bed on the floor. Review of a progress note, dated 8/24/18, indicated the resident fell in the bathroom, and sustained a small abrasion on his/her right thigh from the fall. Review of the investigation report surrounding the 8/24/18 fall indicated the resident fell in the bathroom at 3:10 P.M., and the fall was not witnessed. The report indicated Resident #15 had toileted self and then fell while attempting to transfer self-back into the w/c. The w/c was observed tipped over on its side. The left w/c leg rest was off, and found under the resident's right buttock. The resident sustained [REDACTED]. The report identified Resident #15 was unsteady, had received a diuretic medication, the call light was not in reach, and Resident #15 was still recovering from a recent [MEDICAL CONDITION]. The report also indicated staff had observed the resident 10 minutes prior to the fall. The care plan had not been followed when staff did not assist the resident to the bathroom and did not ensure the call light was in reach as the facility identified it should have been. The report identified the resident was re-orienting on use of the call light, which was an ineffective intervention, since the call light had not been in reach to begin with. The follow-up interventions to prevent further falls included: Resident #15 would educated to call for assistance with all transfers and toileting, and was an ineffective intervention as the resident has cognitive impairment, forgetful, and has dementia. The resident also requires extensive assistance of two staff for toileting. Review of the updated fall care plan, implemented 8/24/18, indicated the following intervention: resident to call for assistance with all transfers and toileting, which is an ineffective intervention due to his/her dementia and impaired cognitive abilities, and he/she was not to be left alone in the bathroom. Review of the progress note, dated 10/3/18, indicated the resident was found on the floor beside the bed at 3:20 A.M. Review of the investigation surrounding the 10/3/18 fall indicated at 3:20 A.M., the resident said he/she was trying to get to the Nursing Station to get car keys, and fell . There was no injury as a result of this fall. A urine culture and analysis was ordered to rule out a urinary tract infection [MEDICAL CONDITION], and supervision was provided. Review of the Quarterly MDS Assessment, dated 10/25/18, indicated the resident continued to require extensive assistance for transfers and used a w/c for mobility, had problems with balance, had one fall with no injury, and the resident received 7 days of antipsychotic, antidepressant and diuretic medications. Review of a 10/31/18 Occupational Therapy (OT) note indicated the resident was screened for positioning in the w/c, and a seat belt was to be used to aid in preventing the resident from sitting in a slouched position. Review of a progress note, dated 11/12/18, indicated three day bladder training would be completed. The results indicated a plan to toilet the resident before meals, after meals, upon rising and before bed. Review of a progress note, dated 11/19/18 at 4:45 P.M., indicated the resident was found on the floor in the bathroom. Review of the investigation surrounding the fall on 11/19/18 at 4:45 P.M., indicated the fall was not witnessed. The resident had been on the toilet, and attempted to pull his/her pants up, lost balance, and fell (resident required extensive assist with transfers, toilet use and dressing, with poor sitting balance). The resident was found on the floor in the bathroom with urine soaked pants, and a 10 centimeter (cm) x 2 cm bruise on the left hip. The Resident complained of a level 8 pain on a scale of 1-10, 10 being the worst pain in left hip when touched, and X-rays were ordered. The X-ray result was negative for a fracture. The plan of care had not been followed related to toileting the resident prior to the evening meal, in accordance with the resident's toileting plan, as evidenced by the Certified Nursing Assistant (CNA) toileting schedule/CNA ADL record. Interventions to prevent further falls were to place a beam alarm to the bathroom door, as a result of this fall. During interview and review of the falls (11/24/17, 7/7/18 with a [MEDICAL CONDITION], 7/19/18, 8/24/18 10/3/18 and 11/19/18) on 1/16/19 at 1:40 P.M., the Director of Nursing (DON) said adequate supervision and effective interventions had not been provided for Resident #15 to prevent falls, one with a [MEDICAL CONDITION] and laceration to the elbow on 7/7/18. The DON said she could not find any evidence that Resident #15 had been toileted, prior to the evening meal, and last fall on 11/19/18, as planned. On 1/10/19 at 9:32 A.M., the surveyor observed Resident #15 sitting in a slouched position in the w/c with a seat belt secured around the resident's waist. The resident was bleeding from a three corner skin tear in the left hand. The resident said he/she must have hit it on the door frame, while trying to navigate the w/c through the doorway.

Based on record review, observations and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents/injuries for 1 sampled residents (#6) of 7 residents with falls in a total sample of 15 residents. For Resident #6, the facility failed to provide the necessary supervision and effective devices to prevent 25 falls in six months. All 25 falls occurred in the resident's room. Twenty two of the twenty five falls were unwitnessed. Despite the multiple falls in the resident's room, the resident's door and curtain were routinely kept shut which prevented visual monitoring. The resident experienced a fracture, multiple abrasions, lacerations and bruises. Findings included: Resident #6 was admitted to the facility in June of 2011 with [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment of 6/30/11 indicated the resident was a high risk for falls. Review of the fall care plan in place 6/30/11 included the following interventions: -Assess risks: medications, gait, pain, blood pressure changes and need to void. -Call light within reach, encourage to use. -Physical and Occupational Referral. Review of the nurse's note of 6/30/11 indicated the resident used a cane for walking and that the resident's gait was unsteady at times. Review of the nurse's note of 7/1/11 indicated the resident was seen by the physical therapist and was encouraged to use the call bell for assistance with transfers. Review of the physical therapy evaluation of 7/1/11 indicated the resident's gait was unsteady and the resident had a history of [REDACTED]. The resident was described as requiring minimal assistance for transfers and ambulation. This evaluation indicated the resident had poor safety awareness/insight concerns. The physical therapist recommended bed and chair alarms for fall risk management. Review of the nurses' notes of 7/3/11 indicated the resident fell at 3:00 A.M., and sustained a laceration with swelling of the right elbow. Review of the fall investigation (incident reports, nurses' notes, witness statements and staff assessments provided by the facility) indicated the laceration was cleansed with normal saline. This investigation indicates the fall was in the resident's room and was not witnessed. The resident apparently tripped over a bedside chair when returning from the bathroom. The room was described as cluttered. The intervention to prevent further falls was to remove the chair. Review of the nurses' notes of 7/5/11 indicated the resident was found on the floor in the resident's room at 1:15 A.M. Swelling was noted in the right shoulder and the resident was complaining of discomfort in the right shoulder. Review of the falls investigation indicated staff heard a thump and found the resident on the floor. Ice was applied to the right shoulder. The physician was notified. The investigation indicated the resident fell while ambulating from the bathroom to the bed. The physician was notified and the resident was transferred to the local hospital emergency room for an evaluation. The resident returned from the emergency room the same day with a [DIAGNOSES REDACTED]. The resident returned with an alarm in the wheelchair and the following orders: -Ice to injury every hour for 15 minutes times two days. -Arm in a sling except for care. -Call for follow-up appointment with orthopedic surgeon. -Percocet 5/325 milligrams, give half tablet every 6 hours as needed. Review of the nurse's note of 7/5/11 indicated the resident was instructed to call for assistance to go to the bathroom but remained non-compliant with this request. A new intervention put in place 7/5/11 to prevent further falls was a bed and chair alarm. Review of the physician's note of 7/6/11 indicated the resident had dementia and experienced a fracture of the right clavicle. Review of the initial Minimum Data Set (MDS) assessment of 7/7/11 described the resident as having short term memory loss with a BIMS (Brief Interview for Mental Status) score of 8/15 (indicating moderate memory loss). The resident was coded as requiring supervision with transfers, ambulation and required minimal physical assist with toilet use. The resident was described as experiencing falls in the past 30 days. Review of the Care Area Assessment (CAA ) of 7/8/11 for falls indicated the resident's [DIAGNOSES REDACTED]. The resident was described as experiencing falls with a fracture. Review of the nurses' notes (from 7/7/11 to 7/11/11) indicated the resident was frequently agitated, attempted to remove bed/chair alarms, and refused staff assistance. Staff continued to instruct resident to call for help when transferring and ambulating. Gait was described as unsteady. The resident was seen by Psychiatric Services and Seroquel (antipsychotic medication) was increased to attempt to improve the resident's compliance with care. Review of the fall's care plan in place 7/11/11 indicated the resident had decreased strength and endurance; had an unsteady gait, was non-compliant with safety measures and was wheelchair dependent due to a fracture of the clavicle. The interventions included: -Fall assessment as needed. -Insure footwear fits appropriately. -Gripper socks if resident allows at bedtime. -Assist to wheelchair. Remind to lock brakes. -Educate on importance of staff assistance. -Bed alarm and wheelchair alarm. Place alarms out of sight and reach of resident. -Psychiatric referral as needed. -Physical and Occupational as needed. Review of the nurse's note of 7/16/11 at 3:15 P.M., indicated the resident had disassembled the alarms. The note does not indicate why the alarms were not out of resident's reach and sight as care planned. Review of the nurse's note of 7/16/11 indicated the resident was found on the floor in the resident's room at 7:25 P.M. No injuries were sustained. Review of the investigation of the fall indicates the resident slid from the wheelchair to the floor while attempting to transfer independently. The staff heard the resident yell for help and found the resident on the floor. The falls investigation was blank as to whether or not the resident's alarms were in place as care planned. Review of the nurse's note of 7/18/11 indicated that the resident was seen by the orthopedic surgeon for follow-up of the fracture of the right clavicle. The new care plan intervention was to use a wheelchair for ambulation and if the resident is unsafe in the wheelchair (backs up rapidly) the resident should be redirected. Review of the nurse's note of 7/19/11 indicated the bed and chair alarms were discontinued. The alarm noise agitated the resident. Review of the nurse's note of 7/21/11 indicated the resident was found on the floor in the resident's room at 3:40 A.M. No injury was noted. Review of the investigation of the fall indicated the staff responded to noise coming from the resident's room. The resident was found on the floor and indicated he/she fell trying to get out of bed. The cause of the fall was determined to be slippery socks. Gripper socks were recommended to prevent further falls (intervention already in care plan). There was no explanation as to why the resident was in bed with slippery socks on. Review of the nurses' notes from 7/22/11 to 7/27/11 indicated the resident continued to be non-compliant with safety precautions such as use of wheelchair for ambulation, independent transfers and use of appropriate footwear. Review of the nurse's note of 7/28/11 indicated the resident was found on the floor in the resident's room at 5:00 A.M. No injuries were observed. The note indicates the resident was non-compliant with asking for help with assistance. Review of the fall investigation indicated the resident fell attempting independent transfer out of bed. The new interventions added to the care plan included: -Apply non-skid strips near the bed. The resident was wearing regular (slippery socks). -Encourage compliance with call bell (despite short term memory problem and demonstrated lack of ability/willingness to use the call bell). Educate on importance of staff assistance. -Update orthopedic surgeon regarding resident's non-compliance. Review of the physician's progress note of 8/1/11 indicates the resident "keeps falling, does not call for help with walking." Review of the nurse's note of 8/4/11 indicated the resident was found on the floor. The resident sustained [REDACTED]. The resident complained of pain on the left elbow and a bruise was noted on the left elbow. Review of the fall investigation indicated staff heard a bang and found the resident face down, on the floor in the resident's room at 8:10 P.M. The resident indicated he/she tripped in his/her room during independent ambulation. The lacerations were cleansed with normal saline and ice was applied. The physician was notified and the resident was transferred to the local hospital emergency room for evaluation. Review of the nurse's note of 8/5/11 indicated the resident returned to the facility with the [DIAGNOSES REDACTED]. No sutures were applied. Dermabond (a liquid adhesive used to close wounds) was applied to the laceration above the eye in the emergency room . Review of the nurses' notes from 8/6/11 to 8/12/11 indicates the resident was not compliant with safety measures as the resident continued to ambulate and transfer without staff assistance. When staff attempted to intervene, the resident became combative. Review of the care plan indicated on 8/12/11 a wireless bed and chair alarm were put in place. Review of the nurse's note of 8/13/11 indicated the resident was verbally abusive to roommate and threw an item at the roommate (did not make contact with the roommate). The resident was slamming the door to his/her room and was ambulating independently. Review of the nurse's note of 8/15/11 indicated the resident became agitated and threw water into the staff bathroom. Review of the nurse's note of 8/18/11 indicated that the resident was found on the floor at 10:50 P.M. Review of the fall investigation indicated the resident stood up from the wheelchair and fell . The resident hit his/her right elbow. No injury was noted. Review of the nurse's note of 8/19/11 indicated the resident was found on the floor by the bed in the resident's room at 6:06 P.M. Review of the fall investigation indicated the resident's alarms were on and sounded. No new interventions were added. The investigation indicates the resident was non-compliant with safety issues. Review of the nurse's note of 8/21/11 indicated the resident was non-compliant, ambulating at will and swearing at staff. The resident's roommate was taken from the room due to concerns for the roommate's safety. Review of the Activity Director's note (of 8/22/11) indicated that the resident preferred to stay in room and did not participate in activity out of the room. Review of the nurses' notes of 8/22/11 and 8/23/11 indicated the resident insisted staff keep his/her bedroom door closed. Spoke with family who felt the resident should be able to keep his/her door shut despite the risk for falls. Review of the nurse's note of 8/26/11 indicated the resident was found on the floor at 1:00 A.M. The resident sustained [REDACTED]. Review of the fall investigation indicated the resident fell during attempted independent transfer from the bed. No light was on in the room. The investigation indicated the alarms were on and functioning. The new intervention was to encourage resident to keep light on at night and to ask for assistance with transfers. Toileting was to be offered every hour when awake and at 10:00 P.M., 12:30 A.M., and 6:00 A.M. Review of the nurse's note of 8/26/11 indicated that the physician was notified at 8:30 A.M. of the fall and abrasion. The physician ordered normal saline cleansing to the abrasion followed by Bacitracin ointment and a dry clean dressing to be applied daily to the abrasion until healed. Review of the nurses' notes from 8/26/11 to 8/30/11 indicated the resident continued to have periods of non-compliance with safety issues. Review of the nurse's note of 8/31/11 at 7:00 A.M., indicated the resident was ambulating in the dark, slamming the bathroom and bedroom doors, using foul language and waking up other residents. Review of the nurse's note of 8/31/11 at 10:30 A.M. indicated the resident stood up independently and was observed to fall. The resident sustained [REDACTED]. The physician was notified and ordered ice to the chest, normal saline cleansing, Bacitracin and clean dressing to the abrasions. Review of the nurse's note of 9/4/11 indicated the resident fell and re-opened an old abrasion to the right knee. Review of the investigation into the fall indicated the alarm sounded and staff responded at 10:30 P.M. The resident was found sitting in the wheelchair. The resident stated he had attempted to go to the bathroom. Five minutes later the resident wheeled his/her self to the nurses' station asking for new pajama bottoms. The resident's pajamas were described as "bloody". The resident indicated he/she fell getting out of bed. The physician was notified of the fall and abrasion, and ordered cleansing of the abrasion with normal saline followed by a clean dressing. The new interventions added to the care plan included a scoop mattress and 15 minute checks. Nurse's note of 9/5/11 indicated the resident was encouraged to ring bell and noted that the resident becomes agitated when staff respond to the alarms. Nurse's note of 9/8/11 indicated the resident was verbally abusive and striking staff. Nurse's note of 9/9/11 indicate the resident was slamming doors and violently yelling "turn off the light". The nurse's note of 9/10/11 indicated the resident continued aggressive behavior toward staff, was unsteady on feet and unaware of safety issues. Review of the nurse's note of 9/13/11 indicated the resident was transferred to a private room. The resident fell in his room attempting independent ambulation. No injuries were sustained. Review of the fall investigation indicated the alarm sounded at 10:30 P.M. Staff responded and saw resident fall landing on his/her back. The resident was ambulating without assistance. Review of the nurse's note of 9/18/11 indicated the resident was found on the floor in the resident's room at 8:35 P.M. No injury was noted. Review of the fall investigation indicated staff responded to a loud bang and found the resident on the floor. The resident stood up without assistance. The alarm was in the off position and did not sound. Review of the nurse's note of 9/19/11 indicated the resident was found on the floor in his/her room at 5:30 A.M. No injuries were noted. Review of the fall investigation indicated the resident was found on the floor after attempting independent transfers. Review of the quarterly MDS assessment of 10/4/11 described the resident as having short term memory loss with a BIMS score of 5/15. The resident was coded as requiring supervision with transfers, ambulation and required minimal physical assist with toilet use. The resident was described as experiencing falls in the past 30 days. Review of the nurse's note of 10/9/11 indicated the resident was found on the floor in the resident's room at 12:30 A.M. The resident sustained [REDACTED]. Review of the fall investigation indicated the resident was trying to find his/her call bell, transferred independently and fell . The alarm did not sound. Review of the nurse's note of 10/9/11 indicated the resident fell again at 7:55 A.M. Staff responded to the alarm sounding and witnessed the resident fall to the floor landing on right knee. The resident sustained [REDACTED]. Review of the fall investigation indicated when the resident attempted to stand and transfer out of bed, the bed rolled backwards. The new intervention was to keep the bed in a locked position and the call bell within reach. Review of the nurse's note of 10/21/11 indicated the resident was found on the floor in his/her room at 4:50 P.M. Review of the fall investigation indicated the resident fell during independent transfers. No injuries were noted. Review nurse's note of 10/24/11 indicated the resident was found on the floor at 1:45 A.M. The resident sustained [REDACTED]. Review of the fall investigation indicated the resident was found on the floor in the resident's room after hearing a loud thud type noise. The new intervention was to remind the resident to use the call bell. The abrasions were cleansed and a dressing applied. Review of the nurse's note of 10/25/11 indicted the resident was found on the floor in the residents room at 3:45 P.M. No injuries were noted. Review of the investigation of the fall indicated staff heard a loud noise and found the resident on the floor in front of the bathroom. Review of the nurse's note of 11/6/11 indicated the resident fell . Review of the fall investigation indicated that the resident was found on the floor near the resident's bathroom door at 12:55 A.M. No injuries were noted. Review of the nurse's note of 11/18/11 indicated the resident's family was notified of the "incident." Review of the fall investigation indicated the resident was found on the floor in the resident's room on 11/18/11 at 1:50 A.M. Staff sitting at the desk heard the resident call for help and went to the room to help the resident. No injuries were noted. The resident was reminded to use the call bell before attempting ambulation. Review of the nurse's note of 12/5/11 indicated the resident fell in the resident's room at midnight. Staff heard noises coming from the resident's room and went to the resident's room and witness the resident fall during independent ambulation. No injuries were noted. Review of the fall investigation indicated the resident was reminded to call for help before transfer/ambulation attempt. Review of the nurse's note of 12/8/11 indicated the resident was found on the floor at 3:30 P.M., in the resident's room. Alarm did not sound. No injuries were noted. Review of the fall investigation indicated the staff responded to the resident's call for help and found resident on the floor. Alarm was on but did not sound. The new intervention was to continue to remind the resident to call for help and to check alarms. Review of the nurse's note of 12/18/11 indicated the resident was found on the floor in the resident's room at 4:30 A.M. No injury was noted. Review of the fall investigation indicated the intervention was to encourage resident to call for assistance. Review of the nurse's note of 12/20/11 indicated the staff heard a thump in the resident's room and found the resident sitting on the floor. No injuries noted. Review of the fall investigation did not indicate if the resident's alarm was on and functioning. Resident was observed 12/21/11 from 9:00 A.M. to 11:45 A.M., to be in the resident's room, in bed, with the door shut and curtain drawn. The surveyor entered the room at 9:00 A.M., 10:30 A.M. and 11:30 A.M. During these times, the resident remained in the room, in bed, with the curtain drawn and door shut. During interview 11/21/11 at 12:35 P.M., Certified Nursing Assistant (CNA) #1 who was assigned to the resident stated the resident insisted on keeping his/her curtain drawn and the door closed. CNA #1 stated that the facility tries to check on the resident frequently but the resident was not on any scheduled checks and yelled if the door was opened. During interview on 12/21/11 at 1:10 P.M., the Administrator and Clinical Nurse Specialist both stated that the resident has had multiple unwitnessed falls in the resident's room while the door was shut and the curtain drawn. Both of these staff stated that they were aware that the resident had short term memory problems, poor safety awareness, and an unsteady gait. Both of these staff stated that the devices, supervision, and interventions were not effective in preventing multiple falls and injuries. During interview on 12/21/11 at 2:20 P.M., RN#1 stated that reminding the resident to ask for help before transferring had not been effective. This nurse stated that the curtain drawn and the door closed does not allow for adequate supervision of the resident. During interview on 12/21/11 at 2:30 P.M., the Director of Nurses (DON) stated that the resident had poor short term memory, impaired safety awareness, behavioral issues, and an unsteady gait. The DON stated that despite 25 falls in the resident's room in which the resident sustained [REDACTED]. The DON said the resident was not on any particular scheduled visual monitoring plan.

Based on record review, observations and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents/injuries for 2 sampled residents (#6 and #13) out of a total sample of 9 residents. For Resident #6, the facility failed to provide the necessary supervision and effective devices to prevent 6 falls in a month (since original survey of 12/21/11). Five of the six falls were unwitnessed. All 6 falls occurred in the resident's room. The resident sustained [REDACTED]. The resident's door was not open sufficiently to allow staff visual monitoring. Resident #13 experienced 4 falls in 14 days. Three of the four falls were unwitnessed. Resident #13 sustained an abrasion during one of the falls. Findings included: 1. Resident #6 was admitted to the facility in June of 2011 with [DIAGNOSES REDACTED]. Review of the record indicated the resident had previously experienced 25 falls in the facility (June to December 21, 2011) and sustained a fracture, bruises and lacerations. Review of the quarterly MDS assessment (of 1/4/12) described the resident as having short term memory loss with a BIMS (Brief Interview for Mental Status) score of 5/15. The resident was coded as requiring supervision with transfers, ambulation and required minimal physical assist with toilet use. The falls care plan was reviewed and revised on 12/22/11 and included the following interventions: -Non-skid strips applied between resident's bed and bathroom. -Urinal placed at bedside. -Every hour toileting offered and urinal emptied. -Signage in the resident's room to remind the resident to call for help. -Dycem added to wheelchair. -Privacy curtain removed. -Resident's door to remain partially opened as resident allows. -Bladder diary to determine patterns and to anticipate resident's need. -Sleep pattern study. -Referrals to primary care physician, urology and neurology. -Interdisciplinary Interaction Tool to encourage and demonstrate improved interaction and supervision of resident. -Wireless bed and chair alarm. -Physical and Occupational therapy as needed. -Gripper socks as allowed when not wearing shoes. Review of the nurse's note of 12/22/11 indicated the resident was found on the floor in the resident's room at 3:15 A.M. This note indicates that ice was applied to a laceration of the back of the head. Review of the falls investigation indicated the resident attempted to transfer independently and fell . The resident was bleeding from the scalp which was cleaned with normal saline and ice was applied. Further review of the nurse's note of 12/22/11 indicated the resident was transferred to the emergency room for an evaluation of the laceration of the head at 8:00 A.M. Review of the 12/22/11 hospital emergency department note indicated the resident had experienced some nausea and vomiting following a fall and was transferred to the emergency room for an evaluation. The laceration on the head was described as very small and shallow and the CT (Computed Tomography) scan of the head was negative. The resident was returned to the facility with no changes in treatment other than to observe the resident. Review of the nurse's note of 12/29/11 indicated that the resident was found with blood on the resident's toes (no specific toes) and the resident indicated that it occurred from the fall the resident experienced the night before. During discussion (2/6/12 at 10:00 A.M.) the Director of Nurses (DON) stated that there was no further information about this event in the clinical record and that a falls investigation was not done as there was no staff report of a fall. Review of the nurse's note of 12/30/11 at 11:00 P.M., indicated the resident was found on the floor in the resident's room at 8:10 P.M. The resident sustained [REDACTED]. The abrasions were cleansed and a clean dressing was applied. Review of the falls investigation of 12/30/11 indicated the resident sustained [REDACTED]. This investigation indicated the alarm was on but not functioning. The investigation did not indicate why the alarm was not functioning. Review of the nurse's note of 12/31/11 (note time 8:00 A.M.) indicated that the resident attempted to get out of bed to use the bathroom and was unable to bear weight on the left foot and was complaining of "extreme pain". An ice pack was applied to the foot. The resident was transferred to the hospital emergency room at 8:45 A.M. Review of the hospital emergency room report of 12/31/11 indicated the resident complained of left leg pain from the knee down and that the resident had abrasions on the left knee. This report indicated the resident had pain in the left knee, tibia, and ankle but no swelling. X-rays of these areas were negative for a fracture. The discharge [DIAGNOSES REDACTED]. The resident returned to the facility with a left leg brace (immobilizer). Review of the care plan of 12/31/11 indicated the facility attempted to provide physical therapy (in an attempt to improve mobility) to the resident, but the resident refused. Review of the nurse's note of 12/31/11 indicated the resident returned from the hospital at 1:45 P.M. The resident continued to experience leg pain and the resident was given Percocet (pain medication) as needed. Review of the nurses' notes of 1/1/12 to 1/3/12 indicated the resident continued to attempt unaided transfers and refused to use the leg brace. Review of the nurses' notes of 1/3/12 indicated the resident became assaultive to staff when staff attempted to intervene with assistance. The physician was notified and the resident was transferred to the local emergency room for an evaluation at 1:20 P.M. The resident returned to the facility with no new orders at 8:00 P.M. Further review of the nurse's note of 1/8/12 indicated the resident was found on the floor in the resident's room at 7:00 P.M. The note indicated that staff were walking by the resident's room and the resident was heard to be calling for help. No injuries were noted. Review of the falls investigation indicated that the resident's alarm was switched to the off position at the nurses' station (the resident's bed and chair alarm were designed to ring at the nurses' station not the resident's room). This investigation indicated staff were inserviced about alarms. Review of the nurse's note of 1/10/12 indicated the resident's alarm sounded at 1:15 A.M., and the resident was found on the floor (on his knees). No injuries were observed. Review of the falls investigation of 1/10/12 indicated the resident fell to his/her knees when attempting independent transfer. Review of the nurse's notes of 1/12/12 indicated the resident was found on the floor at 6:00 A.M. This note indicated the resident's great left toe nail was broken and bleeding. The toe was cleansed and a dressing applied. Review of the falls investigation of 1/12/12 indicated the staff responded to the alarm and found the resident on the floor between the bed and bathroom at 6:00 A.M. Review of the nurses' notes from 1/13/12 to 1/18/12 indicated the resident continued to attempt self transfer. Review of the nurse's note of 1/19/12 indicated staff responded to the resident's alarm at 8:00 P.M. The resident refused assistance with transfer and fell to the floor in the bathroom. Review of the falls investigation of 1/19/12 indicated staff responded to the resident's alarm and offered the resident the urinal. The resident refused to use the urinal. The resident indicated he/she was going to use the bathroom and refused help. The employee waited at the resident's door, heard a bang and found the resident on the floor in the bathroom. This assessment indicated the resident sustained [REDACTED]. Further review of the nurses' notes of 1/20/12 to 1/25/12 indicated the resident remained non-compliant with asking for help before attempting independent transfers. Review of the nurse's note of 1/26/12 included a late entry (from 1/25/12). This late entry note indicated the staff heard a loud bang from the resident's room. Staff responded and found resident attempting to remove a commode from the resident's room. There was no indication that the resident fell . Review of the nurses' note of 1/26/12 with a time of 11:00 P.M., indicated the resident was found with two bruises on buttocks. The resident denied pain but the bruises were sensitive to touch. Review of the investigation of the bruises discovered 1/26/12 indicated the bruises were purple in color, but did not include the size of the bruises. This investigation indicated the resident's last fall (of 1/19/12) was the cause of the purple bruises. Observation of the resident, on 2/6/12 at 8:30 A.M., and again at 9:00 A.M., was of the Resident in his/her room sleeping in bed. The door was ajar, (barely cracked open less than an inch making it impossible to observe the resident) but the resident was not visible from the doorway. Observation on 2/6/12 at 9:30 and 10:00 A.M., revealed the resident's door was shut tight. After knocking on the door, the resident was observed in his/her room, in bed. No care was being provided at the time. Observation of the resident at 10:30 A.M., was of the resident being escorted to the shower room for a shower. The resident was observed again at 10:45 A.M., and 11:05 A.M., in the resident's room. The door was slightly agar (open less than 1 inch) but not open enough to observe the resident. During observation on 2/6/12 at 11:05 A.M., the resident was in his/her room, lying on the bed watching television. During interview on 2/6/12 at 11:10 A.M., the resident indicated that he/she had not experienced any falls since admission to the facility. During interview on 2/6/12 at 2:00 P.M. the DON and Social Worker stated that the facility had not been able to provide the level of supervision the resident required because the resident would not allow the resident's door to be kept open. The DON stated that with the door ajar but not open, the resident was not in visual view of the staff. The DON stated that the resident had experienced 6 falls since the survey (12/21/11), and had been seen in the emergency room twice in 30 days for injuries sustained during the falls. During interview on 2/6/12 at 3:15 P.M., Certified Nursing Assistant #1 stated that the resident would not allow his/her door to be kept open, was not consistently cooperative with waiting for staff assistance, and preferred to spend time alone in his/her room. This CNA stated the resident's care plan called for the resident to be offered toileting every hour. However, this CNA indicated that the resident toileted his/her self on an average every 1/2 hour. During interview on 2/6/12 at 3:30 P.M., the DON stated that there was no documentation in the record that the resident was indeed toileted every hour, and there was no documentation of how frequently the staff observed the resident. The DON stated the facility allowed the resident's door to remain shut. The DON stated the Interdisciplinary Interaction Sheet (instituted to prevent falls) was not consistently utilized by staff and was not consistently documented on by staff. During interview on 2/6/12 at 4:00 P.M., the facility Administrator stated that the facility had completed a 3 day bladder patterning and a sleep study in an attempt to meet the resident's needs so that the resident would not attempt independent ambulation which resulted in falls. However, review of the 3 day voiding patterning indicated the voiding diary was incomplete. Review of the three day voiding pattern (completed by the facility 12/27/11 to 12/29/11) indicated that the resident was not offered toileting every 1-2 hours as the patterning directions indicated. The resident was checked as follows: -12/28/11 the resident was not checked to determine if the resident was wet or dry from 6:00 A.M. until 11:00 A.M. The resident was not checked again until 3:30 P.M. The resident was checked at 6:00 P.M., 8:00 P.M., and 11:00 P.M. -12/29/11 the resident was checked at 5:00 A.M., not again until 8:00 A.M., 10:00 A.M., 3:30 P.M., 6:00 P.M., 8:00 P.M., and 11:00 P.M. During interview on 2/6/12 at 4:00 P.M., the facility Administrator stated that the resident had sustained six falls since the survey of 12/21/11. 2. For Resident #13, the facility failed to provide the necessary supervision and effective devices to prevent 4 falls in a 14 day period of time when this Resident had a functional decline. Three of four falls occurred in the resident's room, and three of four falls were unwitnessed. The resident sustained [REDACTED]. Resident #13 was admitted to the facility in 6/08. This Resident's pertinent [DIAGNOSES REDACTED]. Review of the falls care plan of 8/11 indicated the Resident was at risk for falls related to the need for psychotropic medication to treat mental illness. In addition, this Resident has weakness, decreased strength and endurance. This Resident has a history of falls and uses a wheeled walker for ambulation. This Resident has decreased safety awareness when his/her mood changes. The fall care plan interventions included; - Remind the Resident to always use the walker - Ensure footwear fits appropriately - Remind the Resident to wear glasses - Encourage the Resident to use the call bell when he/she feels weak or tired. Review of the quarterly Minimum Data Set Assessment of 11/25/11 indicated that, according to this Resident's Brief Interview for Mental Status, this Resident was cognitively intact, and was independent with ambulation, transfers and toilet use. Under section C 1300 signs and symptoms of delirium, inattention is a behavior which is present and fluctuates. Inattention is defined as the resident having difficulty focusing attention (easily distracted, out of touch, or difficulty following what is said). Under Section H, bladder and bowel this Resident is always continent of urine and bowel. Review of the nurse's note and falls investigation of 12/28/11 indicated this Resident had an unwitnessed fall on 12/28/11 at 2:20 A.M., in the bathroom while urinating. "He/she fell to the wall and off the toilet." This Resident used the bathroom call bell for help. Ice was applied to this Resident's head. This resident sustained [REDACTED]. This Resident was unable to stand for orthostatic blood pressure readings. Under the room check after the fall, indicated that this Resident's call bell was not in reach of this Resident. This Resident stated, "Lost my balance... and fell in the bathroom." This falls investigation indicated that the Resident's gripper socks will be worn, an extension will be added to the call bell cord, and the staff will check that the Resident's urinal is by the bedside. It also indicated that this Resident had increased weakness of the lower extremities. The falls care plan was updated on 12/28/11 and stated that the Resident fell , and this Resident will remain in his/her wheelchair until Physical Therapy evaluates this Resident on 12/29/11. Review of the Physical Therapy note of 12/29/11 indicated that this Resident exhibits new onset of a decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, and reduced balance. Review of the alteration in mobility care plan of 12/29/11 indicated the following approaches: - Assist this Resident getting in and out of bed with supervised assistance. - Assist this Resident transferring from bed/chair with supervised assistance. - Assist this Resident with ambulation with rehabilitation only at this time. Review of the Certified Nursing Assistant (CNA) Flow sheets of 12/30/11 indicated that this Resident was incontinent of urine on the 11:00 P.M. to 7:00 A.M. shift (when he/she had been previously continent). Review of the nurse's note and falls investigation of 12/30/11 indicated this Resident had an unwitnessed fall on 12/30/11 at 6:30 P.M. A Nurse found this Resident lying on his/her back on the floor with this Resident's head against the bathroom door. The Resident stated that he/she lost his/her balance. This Resident was in his/her wheelchair prior to the fall. Under the question, what was the Resident doing at the time of the fall ? unassisted ambulation was checked. There were no injuries. This Resident was ambulating without assistance and with no wheelchair. The investigation indicated there was poor lighting and that a bladder and bowel assessment would be implemented. The falls care plan was updated on 12/30/11 to include a chair alarm placed on the wheelchair. Review of the Certified Nursing Assistant (CNA) Flow sheets of 12/31/11 indicated that this Resident was incontinent of urine on the 11:00 P.M. to 7:00 A.M. shift. Review of the nurse's note and falls investigation of 1/1/12 indicated this Resident had an unwitnessed fall on 1/1/12 at 2:50 P.M. This Resident had lower extremity weakness and confusion prior to the fall (this Resident's condition before the falls of 12/28/11 and 12/30/11 was checked as being normal). This Resident was in his/her wheelchair prior to the fall in the basement lounge. This Resident approached the nurse and stated that he/she fell downstairs by the soda machine. Under the question, what was the Resident doing prior to the fall? unassisted ambulation was checked. The Resident stated, "I just stood up to get a soda out of the machine and fell back hitting my back on the bookcase." The investigation indicated that the Resident stated he/she shut off his/her alarms. There was no injury. Review of the Bladder Pattern Assessment indicated the bladder patterning was not started until 1/2/12 (3 days after it was determined to be needed for the fall of 12/30/11 to prevent further falls). Review of the CNA Flow Sheet from 1/1/12 to 1/3/12 indicated that this Resident was incontinent of bladder and was toileted. Review of the nurse's note of 1/2/12 indicated this Resident continues to have weakness in his/her legs. Review of the nurse's note of 1/3/12 at 8:00 A.M. indicated this Resident's legs and arms were weak and he/she was sent to the community hospital emergency room for evaluation. This Resident was admitted to the hospital on [DATE]. Review of the Community Hospital discharge summary of 1/6/12 indicated this Resident had generalized deterioration in health, increased extremity weakness for 2 weeks. He/she started coughing productive yellowish phlegm about 7 to 10 days prior to his/her presentation to the Emergency Department (ED). This Resident was found to have possible pneumonia with subsequent exacerbation of his/her chronic obstructive lung disease. He/she was found to also have a urinary tract infection. This Resident had been having urinary incontinence at the Nursing Home for about 7 days prior to his ED visit. The urinary incontinence may have been secondary to his/her urinary tract infection. In addition, he/she was found to have urinary retention with almost 1 liter of urine. He/she voided (urinated 735 milliliters (ml) of urine with 300 ml left in the bladder. Both infections were treated with an antibiotic, and this Resident was transferred back to the facility on [DATE]. Review of the nurse's note and falls investigation of 1/10/12 indicated this Resident had a fall on 1/10/12 at 9:40 A.M., in his/her room witnessed by the housekeeper cleaning this Resident's room. This Resident was transferring from the bed to his/her wheelchair and lost his/her balance and fell on to his/her buttocks. This Resident stated that he/she was going to the bathroom. During an interview with Nurse #1 on 2/6/12 at 2:45 P.M., regarding the fall of 12/30/11, she stated," He/she is suppose to be getting assistance (from the staff) but was not, and he/she was putting away clothes (at the time of the fall)." For the 3rd fall of 1/1/12, Nurse #1 stated she was on duty, when he/she fell and he/she was confused, which was not his/her usual baseline. This Resident thought he/she was already been given his/her medications when they were not. This Resident was in the basement when he/she fell the 3rd time, and this Resident was supposed to be given assistance when he/she stood up or ambulated, and was not. When the Surveyor asked if any of the staff were near him/her to supervise him/her in the Lounge when he/she went down to get a soda and fell , Nurse #1 said, "No." She stated, "We are use to (him/her) being active. We do not do as well, when the Residents start to not do well ( get sick)." During an interview with Nurse #1 on 2/6/12 at 3:00 P.M., she stated that the Resident's falls were a new problem starting on 12/28/11. In addition, this Resident's incontinence was a new problem starting on 12/30/11 in a Resident who had been continent of urine. When the Surveyor asked Nurse #1 what can the new onset of urinary incontinence mean, she indicated that it could be a UTI. She said, "We may have taken a urine dip stick to see if he/she had a UTI, we routinely take dip sticks, if we suspect a UTI." Nurse #1 then reviewed the Resident's chart and said, "No, a urine dip stick was not done." We did a urinary patterning and it indicated that this Resident was frequently incontinent of urine." She indicated that the urinary patterning was not completed since the Resident was hosptalized on [DATE]. For the 4th fall on 1/10/12, Nurse #1 indicated that the nursing staff did not witness this Resident fall in his/her room, the housekeeper was in the Resident's room and witnessed this Resident falling. During an interview with Nurse #1, on 2/6/12 at 3:05 P.M., she stated that this Resident had three unwitnessed falls and 3 of the falls were in the resident's room. She was aware that this Resident had been functionally declining over a 2 week period of time and had poor safety awareness. Nurse #1 was also aware that the devices, supervision, and interventions were not effective in preventing his/her 4 falls.