Every finding on record at Bourne Manor Extended Care Facility

Based on observation, interview, and record review, the facility failed to follow the manufacturer's directions for application of a registered pesticide (Environmental Protection Agency (EPA) Registration #44446-80) to prevent exposure to residents. Specifically,1. On six evenings over a three-week span, the facility applied a pesticide in the main kitchen without protective measures in place to prevent cross contamination of the pesticide on food prep surfaces, kitchen equipment, condiment packages, small food carts (used to deliver nourishments to the kitchenettes), and meal trucks. The facility failed to clean the food contact surfaces (dishes, pots, pans, cutting boards, utensils), equipment, and carts, after the application, including the inside and outside of the meal trucks which were used to deliver food trays to the units and residents' rooms.2. The facility failed to have a Material Safety Data Sheet (MSDS) in the facility for the pesticide which was being used to control cockroaches. Findings include:Review of the facility's policy titled Environmental Services Guidelines, dated September 2011, indicated but was not limited to the following:-All chemicals used in the facility must have an approved EPA registration number; Be labeled with the product name, product action, and correct use.-Safety concerns and the emergency response needed in case of accidental exposure/ingestion are listed in the Material Safety Data Sheet (MSDS) Book. Review of the EPA information data sheet and the instructions printed on the can for the Pesticide spray with the EPA Registered No. 44446-80 indicated but was not limited to:- Active ingredient: Permethrin 0.50% (pesticide used to kill bugs)-Precautionary statements hazardous to humans and domestic animals-Caution: Harmful if absorbed through skin. Causes moderate eye irritation. Avoid contact with skin, eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco or using the toilet.-Read entire label before each use.Use restrictions:-Do not apply as broadcast treatment to indoor surfaces at residential sites, including nurseries, daycare centers, schools, hospitals and nursing homes.-Except when applying to pets, livestock, clothing, do not allow adults, children, or pets to enter until vapors, mist and aerosols have dispersed, and the treated area has been thoroughly ventilated or dried.-Except when applying to pets, Livestock, clothing, do not apply this product in a way that will contact workers or other persons, either directly or through drift.-Except when applying to pets, Livestock, clothing, only protected handlers may be in the area during applications.-In home, cover all food processing surfaces and utensils during treatment and thoroughly wash before use. Cover and remove exposed food.-Do not apply when food is present.-Do not use in food areas of food handling establishments, restaurants, other areas where food is commercially prepared or processed. Do not use in serving areas while food is exposed or processed.-Cockroaches: Spray into hiding places such as cracks and crevices, behind sinks, cabinets, along base boards, around drains and plumbing, hitting insects with spray whenever possible. Retreat if infestation occurs, but not more than once every two weeks. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: Chapter 7 Poisonous or Toxic Materials:-7-202.12 Conditions of Use. POISONOUS OR TOXIC MATERIALS shall be: (A) Used according to: (1) LAW and this Code, (2) Manufacturer's use directions included in labeling, and, for a pesticide, manufacturer's label instructions that state that use is allowed in a FOOD ESTABLISHMENT, P (3) The conditions of certification, if certification is required, for use of the pest control materials, P and (4) Additional conditions that may be established by the REGULATORY AUTHORITY; and (B) Applied so that: (1) A HAZARD to EMPLOYEES or other PERSONS is not constituted, P and (2) Contamination including toxic residues due to drip, drain, fog, splash or spray on FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE SERVICE and SINGLE-USE ARTICLES is prevented, and this is achieved by: P (a) Removing the items, P (b) Covering the items with impermeable covers, P or (c) Taking other appropriate preventive actions, P and (d) Cleaning and SANITIZING EQUIPMENT and UTENSILS after the application. During an interview on 5/5/26 at 8:45 A.M., the Food Service Manager (FSM) said there has been an ongoing cockroach problem in the kitchen that she first reported in July 2025. The FSM said she contacted the Maintenance Director after her staff reported cockroach sightings in the kitchen. At that time, the FSM said the Maintenance Director said they were wood cockroaches and they would not be a problem. The surveyor requested to see the text message confirming the conversation in July 2025. Review of a text message, dated 7/25/25, from kitchen staff to FSM indicated but was not limited to the following:-Kitchen staff notified FSM there were roaches at the coffee machine.-FSM responded she will text Maintenance Director now. Maintenance Director said they were wood roaches.-Kitchen staff responded, Yea that's what he just came in and told us. He said it was not like regular roaches where they infest and stuff like that so he said we should be OK. Review of an email chain communication, dated 12/28/25, from the FSM to Administrator #3 indicated, I am having a Roach problem in the kitchen now, Maintenance Director says that they are wood roaches, but at this point it is becoming sketchy. They hang around the water/warm areas such as under my steam table and around the coffee machine. I don't know if we can get a pest control person in soon. Response from Administrator #3 indicated, OK, I will address. Thanks.Review of e-mail communication, dated 2/6/26, from the FSM to the Infection Preventionist indicated also, just for the paper trail, roaches galore. 1. During an interview on 5/6/26 at 3:11 P.M., the Maintenance Director said there has been a cockroach problem in the kitchen since the garbage disposal broke (December 2025). The Maintenance Director said they were using Pest Control Company (PCC) #1 who advised him to perform additional spraying to help control the cockroach problem. The Maintenance Director said the pest control company did not recommend a specific spray to use; he ordered a case (12-16 oz cans) of bug killer which his vendor carried (Product ordered was labeled with EPA Reg # 44446-80-66114). The Maintenance Director said the Maintenance Assistant Staff #1 and himself sprayed the kitchen and the food trucks on Friday and Saturday nights starting 4/10/26. The Maintenance Director said he applied the chemical in cracks, crevices, under the tables, under the sinks in the main kitchen and dish room and sprayed the food carts.During an interview on 5/6/26 at 3:47 P.M., the FSM said she was made aware the Maintenance Director was spraying in the kitchen on Friday and Saturday nights by a text she received from Administrator #3. The FSM said she was never informed of the chemical they were spraying, where or what they were spraying, and neither herself nor other kitchen staff were given any special instructions for preparation before the spraying occurred or cleaning after the spraying. Review of a text message, dated 4/10/26 at 8:46 P.M., from Administrator #3 to FSM indicated FYI. From Maintenance Director went into spray.During an interview on 5/7/26 at 8:40 A.M., the Maintenance Director toured the kitchen with the surveyor and showed the surveyor the areas where he sprayed the pesticide in the kitchen. The Maintenance Director said he sprayed in the main kitchen 4/10/26, 4/11/26, 4/17/26, 4/18/26, 4/24/26, and 4/25/26, and did not spray last weekend (5/1/26 and 5/2/26). The Maintenance Director said he sprayed it in the dish room, under the table surfaces, the legs, base boards, around the dish machine (broken) heat booster, and around the drain. The Maintenance Director said in the main kitchen he sprayed under the table's bottom shelves and the legs of all the tables, including the tables the juice machine and coffee machine were on, between the appliances, under the refrigerator, under the sinks, and the legs/wheels of all carts in the kitchen. The Maintenance Director said he sprayed every crack and crevice he could see that cockroaches may go in. The Maintenance Director said he pulled the food trucks from the dining room and sprayed them outside and inside including each shelf the resident food tray goes on. The Maintenance Director said he did not provide any instructions to kitchen staff on where he sprayed or any instructions for cleaning before using the food trucks to transport food or any dishes or surfaces in the main kitchen. The Maintenance Director said he assumed they cleaned them before they used them. The Maintenance Director said he did not cover anything in the kitchen before he sprayed or removed any items from the kitchen.On 5/7/26 at 8:42 A.M., the surveyor made the following observations in the kitchen:-storage rack on the second to bottom shelf was tray of condiments containing individual packages. On the bottom shelf were additional individually packaged condiments.-Pallet bottoms were stacked on top of the plate warmer machine. The dome tops were stored on and open rack on wheels.-Plastic storage rack with four shelves which stored clean drinking glasses open to air.-Under the prep tables stored clean steam table covers, pans, bowls, pots and pans, strainers, cutting boards. During an interview on 5/7/26 at 8:45 A.M., the Maintenance Director said he did not cover or remove any of the above listed items, observed by the surveyor, when spraying the pesticide. During an interview on 5/7/26 at 12:25 P.M., the Consultant of Pest Control Company (PCC) #2 said he did the consultation two weeks ago and recommended doing some spraying in the evening. The Consultant said there is a process for night spraying to minimize the pesticide contamination and harming people. He said this would include covering all food preparation areas with plastic and removing as much stuff from the kitchen as possible. 2. During an interview on 5/6/26 at 3:11 P.M., the Maintenance Director said he ordered a case (12-16 oz cans) of bug killer which his vendor carried (Product ordered was labeled with EPA Reg # 44446-80-66114). The surveyor requested the MSDS for the product. The Maintenance Director said he does not have a Safety Data Sheet for this product. During an interview on 5/6/26 at 3:47 P.M., the FSM said she was never informed of the chemical they were spraying, where or what they were spraying, and neither did her staff. The FSM reviewed the MSDS binder and said she did not have MSDS information for the chemical EPA Reg. 44446-80-66114.During an interview on 5/6/26 at 4:25 P.M., the Maintenance Director provided the surveyor with the MSDS for the pesticide (EPA Reg. 44446-80) he sprayed in the kitchen. He said he has not read it. During an interview on 5/11/26 at 12:10 P.M., Administrator #3 said she was not aware the Maintenance Director was spraying a pesticide (EPA Reg. 44446-80) in the main kitchen and the hallway outside the kitchen to kill cockroaches. She thought it was the pest control company doing the spraying. Refer to F812, F908, and F925

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Monitor the dishwasher sanitation chemical agent after switching from high temperature dishwasher to chemical sanitation for undetermined time frame to ensure all dishware was properly sanitized; and2. Ensure the main kitchen, dish room, and food dry storage area was maintained in clean and sanitary condition; and 3. Ensure wastewater from the broken garbage disposal was not allowed to openly discharge on dish room floor for 70 days before being repaired. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions, dated 5/9/2018, indicated but was not limited to the following:The intent of this requirement is to ensure that facilities:-Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for preparation of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes.-Contaminated equipment: Equipment can be contaminated in various ways, including but not limited to: Improper equipment sanitation procedures.-Dry food storage. The focus of protection for dry storage is to keep non refrigerated foods, disposable dishware, and napkins in a clean, dry area, which is free from contaminants. Controlling temperature, humidity, rodent and insect infestation helps prevent deterioration or contamination of the food.-Equipment and utensil cleaning and sanitation: A potential cause of foodborne outbreaks is improper cleaning (Washing and sanitizing) of contaminated equipment.-Dishwashing machines, operated according to manufacturer specifications, wash, rinse, and sanitize dishes and utensils used in either heat or chemical sanitation.Low temperature dishwasher (chemical Sanitation):a. Wash: 120 F Wash; andb. Final rinse: 50 parts per million hypochlorite (chlorine) on dish surfaces in final rinse.Dietary Department Responsibilities:-All equipment must be kept clean at all times. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:-4-302.14 Sanitizing Solutions, Testing Devices. Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentration of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic.-4-501.114 Machine Washing and Sanitizing - Dishwashing machines use either heat or chemical sanitization methods. Manufacturers' instructions must always be followed. 1. During the initial tour of the kitchen on 5/5/2026 at 8:30 A.M., the surveyor observed Dietary Staff (DS) #3 and DS #4 operating the dishwasher. The Dishwasher Temperature Log (DTL) indicated for May 2026, the wash temperature was recorded to be 140 Fahrenheit (F) and sanitation temperature to be 160 F. The DTL indicated the wash temperature should be 160 F and rinse was to 180 F (High temp dish machine). During an interview on 5/5/26 at 8:32 A.M., DS #4 said he does not check the chemical concentration for the dishwasher, and he pointed to the temperature gages on the dish machine and then pointed to the DTL sheet on the wall. During an interview on 5/5/2026 at 8:33 A.M., DS #3 said the dish machine was switched to a chemical sanitation because the heat booster (heats the dish washer water to reach a temperature of 180 F to sanitize the dishes) has been broken. DS #3 said he does not check the chemical sanitation level and added nobody else checks the sanitation level. The surveyor requested the dish washer sanitation level be checked. On 5/5/2026 at 8:38 A.M., DS #3 checked the dish washer sanitation level with chlorine test strips. The test strip was observed to stay white in color, indicating zero chemical sanitation present. The surveyor then observed the chemical sanitation container attached via tubing from the dish machine to be empty. During an interview on 5/5/2026 at 8:45 A.M., the Food Service Manager (FSM) said the vendor has been out to check the chemical sanitation levels recently when the Town Board of Health was here and they had concerns with the chemical sanitation level. She said the vendor checked the sanitation level and said it was working fine and gave her testing strips. The FSM said the heat booster has been broken since January 2025 and that's when they switched the dishwasher from high temperature sanitation to low temperature chemical sanitation. FSM said initially they were checking the sanitation level, but it was always good, so the staff stopped checking it. FSM said if the chemical sanitation level is not correct, the dishes are not being sanitized. The FSM said she does not know when the staff stopped checking sanitation level. 2. On 5/5/26 at 8:20 A.M., the surveyor observed the following in the main kitchen and areas abutting the kitchen:-The floor was visibly dirty with food particles and debris throughout the main kitchen, dry storage room, FSM office floor, and the dish room.-In the dish room there were live cockroaches crawling up the wall.-In the dish room there were two black folded rubber mats on top of the heat booster which were visibly soiled and had numerous dead cockroaches stuck to the mat.-Entrance to the dish room at the base of the door jambs- the structure was rotting and had holes along with dirt and debris.-The base board in the main dining room which abuts the dish room had signs of water damage and was pulling away from the wall.-The wall in the hallway which abuts the dish room had visible water damage and was buckling away from the wall (it was not the original wall; the lower half had been replaced at some time).-Under the refrigerator (out of service), ice machine, and the table with the juice machine was a large amount of dirt, debris, and dead cockroaches.-The floor under the juice machine table was sticky.-On the juice machine/coffee table there were dead cockroaches. -There was standing water under the ice machine, the three-bay sink had a bucket under it collecting leaking water which was black in color, and there was an excessive amount of standing water on the dish room floor. There was a bucket under the garbage disposal which was full and leaking over onto the dish room floor.-The dry storage room floor and underneath the storage racks were visibly dirty with food particles and debris.-The juice machine drain grate had a build-up of dried juice.-The dish machine internal food trap bottom layer was filled with macaroni and peas.-The outside of the microwave was visibly dirty, including the door and the handle. The inside top of the microwave was dirty.-The inside of the door to exit the kitchen was visibly soiled.-The ceiling vent at the exit to the kitchen was ladened with dust build up. -The clear plastic door to the ice cream freezer was visibly soiled.-The inside of the prep sink counter and two bays were visibly dirty.-The top of the plate warmer machine was tacky to touch (grease build up). During an interview on 5/5/26 at 9:06 A.M., the FSM said she does not have a cleaning schedule for anything in the kitchen except the food cart power washing schedule she just started at the recommendation of Pest Control Company (PCC) #1. During an interview on 5/6/26 at 3:11 P.M., the Maintenance Director said there has been a cockroach problem in the kitchen since the garbage disposal broke (December 2025). The Maintenance Director said PCC #1 did recommend cleaning the kitchen better, removing the broken heat booster in the kitchen because it may be holding water, and removing the food trucks from the kitchen and power washing them. The Maintenance Director said the new PCC #2 also made new recommendations including getting a cleaning schedule for the kitchen and having staff do a better job cleaning. He is not sure if that has started. In addition, because of the water damage to walls PCC #2 recommended they open the walls to evaluate the sponginess of the walls (moisture assessment) and what was going on behind them. During an interview on 5/6/26 at 3:47 P.M., The FSM pointed to the black mats folded on the heat booster and said the staff would stand on the black mats, so they weren't standing in the dirty water.On 5/6/26 at 3:48 P.M., the Surveyor observed the two black mats with the FSM and noted the mats were dirty and had dead cockroaches stuck to them. The FSM removed the top mat and live cockroaches, and debris fell to the floor. The surveyor removed the second black mat from the heat booster, and additional live cockroaches fell to the ground with additional debris including dead cockroaches and what appeared to be cockroach egg sacs. The live cockroaches scurried under the dish machine and down into the cracks around the drain. During an interview on 5/6/2026 at 3:50 P.M., the FSM said the staff do not use the mats anymore and said no they have not been cleaned since they stopped using them (garbage disposal was repaired 2/12/26).During an interview on 5/7/26 at 10:25 A.M., the Clinical Nurse and Administrator #2 (covering for the day) said they were aware of the cockroach problem in the kitchen, and they were working with a new pest control company. The Clinical Nurse said they were not aware of the concerns with standing water in kitchen or the leaking sinks. During an interview on 5/11/2026 at 9:46 A.M., [NAME] President of Development and Maintenance said he was not aware of the cockroach problem in the kitchen, the garbage disposal issues, the leaking pipes in the kitchen, or the water damage to walls in the kitchen.During an interview on 5/6/2026 at 3:47 P.M., Food Service Manager (FSM) said she does not have a cleaning schedule for the kitchen, the cleaning is just done every day with typical day to day cleaning. The surveyor reviewed the sanitation concerns in the kitchen with the FSM, and she said she was aware the kitchen was not as clean as it should have been. 3. During an interview on 5/6/26 at 3:47 P.M., the FSM said the garbage disposal leak went on for over two months and she had a bucket under the sink to catch the dirty water, but it was coming out so fast the bucket would overflow with garbage water onto the floor. She said the dietary staff would squeegee the dirty water across the dish room floor to the open drain. The FSM pointed to the black mats folded on the heat booster and said the staff would stand on the black mats, so they weren't standing in the dirty water.On 5/6/26 at 3:48 P.M., the surveyor pointed out the grout disrepair and the holes in the grout around the drain. The surveyor asked the FSM if the garbage water was going into the subflooring and she was observed to shrug and make the gesture she didn't know.During an interview on 5/7/26 at 8:50 A.M., Dietary Staff #3 said when the garbage disposal was broken for months it was like a dirty river of water across the dish room floor. Dietary Staff #3 said food would just come out at the bottom of the disposal. Dietary Staff #3 said we would push the water across the floor to the drain; it was a mess.During an interview on 5/11/2026 at 9:46 A.M., [NAME] President of Development and Maintenance said grout in the dish room is shot. He said the kitchen was shut down over the weekend and we are going to re-grout the dishwashing room floor. Review of the Capital Equipment Request (CER) to repair the kitchen garbage disposal indicated it was initiated 12/3/25 with final sign-off from the President on 12/15/25.During a telephonic interview on 5/14/26 at 9:51 A.M., Contractor #1 said the garbage disposal work was completed on 2/12/26.During the dates 12/3/2025 through 2/12/2026, there were 70 days in which raw sewage from the leaking garbage disposal was drained across the dish room floor into the cracks in the grout, holes around the drain, and into the drain presenting a sanitation concern. Refer to F908 and F925

Based on observation, interview and document review, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to:1. Promptly repair or replace a broken garbage disposal resulting in raw sewage overflowing onto to the dish room floor, resulting in dietary staff squeegee the sewage discharge across the room to the open drain;2. Promptly fix leaking water from the recent replacement garbage disposal resulting in water draining on the dish room floor with active cock roach infestation present. 3. Promptly fix heat booster which broke in January 2025;4. Promptly obtain an electrician to repair the electrical short resulting in the plate warmer and refrigerator in main kitchen being inoperable for approximately two weeks. Findings include: Review of the Facility Assessment, revised April 2026, indicated but was not limited to the following:-[Facility Name] has a preventative maintenance process to ensure adequate equipment exists and is maintained and promotes and protects the health and safety of our residents. Below are listed our resources and services. -[Facility Name] has the following vendor contracts and contractors to provide the service needed during normal operations in emergencies, to meet the needs of residents, regulations, operations, maintenance, and staff training requirements.-There was no vendor list attached. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -Chapter 4 Equipment, Utensils, and Linens:4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. -Chapter 5 Water, Plumbing, and Waste5-205.15 System Maintained in Good Repair. A plumbing system shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair.Design and construction 5-403.11 Approved Sewage Disposal System. SEWAGE shall be disposed through an APPROVED facility that is: (A) A public SEWAGE treatment plant; P or (B) An individual SEWAGE disposal system that is sized, constructed, maintained, and operated according to LAW. P 5-403.12 Other Liquid Wastes and Rainwater. Condensate drainage and other nonSEWAGE liquids and rainwater shall be drained from point of discharge to disposal according to LAW. 1. Review of an email, dated 12/13/25, from the Food Service Manager (FSM) to Maintenance Director and copied to Administrator #3, indicated The disposal in the dish room is completely down. I know we put a Capital Equipment Request (CER) in for a new one but now it won't turn on. It was working fine, minus the leak, last night.-Administrator #3 responded Anyway, to push this through? The dish room is unsafe due to the leak and now the dishwasher is having to stick their arm in filthy water to get the disposal to empty.Review of Contractor #1's initial quote to repair the garbage disposal was received by the facility via email on 12/2/25.Review of the CER indicated it was initiated 12/3/25 with final sign-off from the President on 12/15/25.Review of the payment to Contractor #1 was electronically transferred on 1/16/26. This represented 32 days after final approval for the replacement of the garbage disposal.During an interview on 5/6/26 at 3:11 P.M., the Maintenance Director said the cockroach problem got very bad since the garbage disposal broke.During an interview on 5/6/26 at 3:47 P.M., the FSM said the garbage disposal leak went on for over two months and she had a bucket under the sink to catch the dirty water, but it was coming out so fast the bucket would overflow with garbage water onto the floor. She said the dietary staff would squeegee the dirty water across the dish room floor to the open drain. The FSM pointed to the black mats folded on the heat booster and said the staff would stand on the black mats, so they weren't standing in the dirty water.On 5/6/26 at 3:48 P.M., the surveyor pointed out the grout disrepair and the holes in the grout around the drain. The surveyor asked the FSM if the garbage water was going into the subflooring and she was observed to shrug and make the gesture she didn't know.During an interview on 5/7/26 at 8:50 A.M., Dietary Staff #3 said when the garbage disposal was broken for months it was like a dirty river of water across the dish room floor. Dietary Staff #3 said food would just come out at the bottom of the disposal. Dietary Staff #3 said we would push the water across the floor to the drain; it was a mess.During a telephonic interview on 5/14/26 at 9:51 A.M., Contractor #1 said he sent the original quote for the work on 12/2/25 and did not order the special-order garbage disposal until full payment was received on 1/16/26. The contractor said it took a couple weeks for the garbage disposal to come in, once he received it the work was completed on 2/12/26.During an interview on 5/11/26 at 12:10 P.M., Administrator #3 said she was not sure what took so long to get the garbage disposal repaired, she went out on medical leave at the end of December 2025.2. During an interview on 5/6/26 at 3:47 P.M., the FSM said after the garbage disposal was replaced in February 2026, the pipe under the sink started leaking water, so she put a plastic bucket underneath the sink to catch the water. The FSM said Contractor #1 was supposed to return and fix the leak but never did. The surveyor observed the bucket to be full and overflowing onto the dish room floor with large puddles of water under the sink against the wall and pooling out to the middle of the dish room.During a telephonic interview on 5/14/26 at 9:51 A.M., Contractor #1 said he was never contacted to come out and fix the leak on the garbage disposal that his company installed on 2/12/26.3. During an interview on 5/6/26 at 3:47 P.M., the FSM said the heat booster for the dishwasher has been broken since January 2025. The FSM said we got a quote in January 2025, but it was never fixed and are now using chemical sanitation. The FSM said she just got for approval for the heat booster to be fixed.During an interview on 5/6/26 at 4:30 P.M., the Maintenance Director said he just got approval for the dishwasher heat booster. He said it was a budgetary issue, you put in requests and it gets approved according to the budget.Review of Contractor #2's initial quote to repair the heat booster for the dishwashing machine was dated 1/14/25.Review of the CER indicated it was initiated 1/16/25 and only contained one signature from the initial requester. The Administrator, Regional Director, V.P. of Operations, Finance AVP and the President's signatures were all blank.Review of a second CER indicated it was initiated 5/5/26 and it contained all the required signatures, including the President's.During an interview on 5/11/26 at 12:10 P.M., Administrator #3 said she would have to look into why this was not followed through on. She said she thinks now they are using chemical sanitation until it is fixed.During an interview on 5/11/26 at 1:30 P.M., Administrator #1 said the heat booster for the dishwasher was just approved. Administrator #1 said she does not know why the CER from 1/16/25 was not completed.4. During an interview on 5/5/26 at 8:45 A.M., the FSM said the only equipment not working in the kitchen now is the refrigerator and hot plate machine which just broke. The FSM said they are on the same electrical circuit, and they are just waiting for an electrician.Review of an email, dated 4/27/26, from the FSM to Administrator #1 and copied to Administrator #3 and Maintenance Director, indicated Maintenance Director is working on an electrical short that I have in the kitchen. It has shut down my front reach in fridge as well as my hot plate machine. I am concerned that the state is going to walk in and I am not providing hot food due to the hot plate machine not working. Maintenance Director said we're on hold to get an electrician. Anything that can be done? -Maintenance Director replied on 4/27/26 indicating, I have tried everyone to get them here. They all said the same thing as we owe them money. I have also reached out to friends to help, and they still have not been paid when the dumper (sic) was installed. At the time of exit on 5/11/26 the reach in refrigerator and the hot plate machine were not in working order. Refer to F925

Based on observation, interview, and document review, the facility failed to implement an effective pest control program to ensure the facility was free of cockroaches. Specifically, the facility had an active cockroach infestation in the main kitchen, with additional staff sightings in the food trucks during meal delivery, in the unit nurses' stations, unit kitchenettes, and the employee breakroom. Findings include: Review of the facility's policy titled Pest Control, dated 7/9/24, indicated but was not limited to the following:-Our facility shall maintain an effective pest control program.-The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -Chapter 6 Physical Facilities6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; Chapter 6 - 9 FDA Food Code 2022 Chapter 6. Physical Facilities (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions. On 5/5/26 at 8:15 A.M., the surveyor observed the following in the main kitchen and areas abutting the kitchen:-The floor was visibly dirty with food particles and debris throughout the main kitchen, dry storage room, Food Service Manager's (FSM) office, and the dish room.-In the dish room there were live cockroaches crawling up the wall.-In the dish room there were two black folded rubber mats on top of the heat booster which were visibly soiled and had numerous dead cockroaches stuck to the mat.-Entrance to the dish room at the base of the door jambs- the structure was rotting and had holes along with dirt and debris.-The base board in the main dining room which abuts the dish room had signs of water damage and was pulling away from the wall.-The wall in hallway which abuts the dish room had visible water damage and was buckling away from the wall (It was not the original wall; the lower half had been replaced at some time).-Under the refrigerator (out of service), ice machine, and the table with the juice machine was a large amount of dirt, debris, and dead cockroaches.-The floor under the juice machine table was sticky.-On juice machine/coffee table there were dead cockroaches.-FSM's office floor which enters into the main kitchen, was visibly dirty. -There was standing water under the ice machine, the three-bay sink had a bucket under it collecting leaking water which was black in color, and there was an excessive amount of standing water on the dish room floor. There was a bucket under the garbage disposal which was full and leaking over onto the dish room floor.-The dry storage room floor and underneath the storage racks were visibly dirty with food particles and debris.-The juice machine drain grate had a build-up of dried juice.-The dish machine internal food trap bottom layer was filled with macaroni and peas.-The outside of the microwave was visibly dirty, including the door and the handle. The inside top of the microwave was dirty.-The inside of the door to exit the kitchen was visibly soiled.-The ceiling vent at the exit to the kitchen was ladened with dust build up. -The clear plastic door to the ice cream freezer was visibly soiled.-The inside of the prep sink counter and two bays were visibly dirty.-The top of the plate warmer machine was tacky to touch (grease build up). During an interview on 5/5/26 at 8:45 A.M., the FSM said there has been an ongoing cockroach problem in the kitchen that she first reported in July 2025. The FSM said she contacted the Maintenance Director after her staff reported cockroach sightings in the kitchen. At that time, the FSM said the Maintenance Director said they were wood cockroaches and they would not be a problem. The surveyor requested to see the text message confirming the conversation in July 2025. Review of a text message, dated 7/25/25, from kitchen staff to FSM indicated but was not limited to the following:-Kitchen staff notified FSM there were roaches at the coffee machine.-FSM responded she will text Maintenance Director now. Maintenance Director said they were wood roaches.-Kitchen staff responded, Yea that's what he just came in and told us he said it was not like regular roaches where they infest and stuff like that so he said we should be OK. Review of an email chain communication, dated 12/28/25, from the FSM to Administrator #3 indicated I am having a roach problem in the kitchen now. Maintenance Director says that they are wood roaches, but at this point it is becoming sketchy. They hang around the water/warm areas such as under my steam table and around the coffee machine. I don't know if we can get a pest control person in soon. Response from Administrator #3 indicated OK, I will address. Thanks.Review of an email communication, dated 2/6/26, from the FSM to the Infection Preventionist indicated also, just for the paper trail, roaches galore.During an interview on 5/5/26 at 9:06 A.M., the FSM said she does not have a cleaning schedule for anything in the kitchen except the food cart power washing schedule she just started at the recommendation of Pest Control Company (PCC) #1. The FSM said maybe if they started treating the cockroaches sooner the problem wouldn't be as bad.Review of the Food Cart Deep cleaning schedule indicated the food carts were deep cleaned on 3/10/26 and 4/7/26.During an interview on 5/6/26 at 3:11 P.M., the Maintenance Director said there has been a cockroach problem in the kitchen since the garbage disposal broke (December 2025). The Maintenance Director said they were not happy with the first PCC (#1), so they hired a second PCC (#2) about three weeks ago. The Maintenance Director said PCC #1 did recommend cleaning the kitchen better, removing the broken heat booster in the kitchen because it may be holding water, and removing the food trucks from the kitchen and power washing them. The Maintenance Director said the new PCC #2 also made new recommendations including getting a cleaning schedule for the kitchen and having staff do a better job cleaning. He is not sure if that has started. In addition, because of the water damage to walls he recommended they open the walls to evaluate the sponginess of the walls (moisture assessment) and what was going on behind them. During an interview on 5/6/26 at 3:47 P.M., the FSM said PCC #1 laid down some traps and sprayed. The FSM said the garbage disposal leak went on for over two months and she had a bucket under the sink to catch the dirty water, but it was coming out so fast the bucket would overflow with garbage water onto the floor. She said the dietary staff would squeegee the dirty water across the dish room floor to the open drain. The FSM pointed to the black mats folded on the heat booster and said the staff would stand on the black mats, so they weren't standing in the dirty water.During an observation with interview on 5/6/26 at 3:48 P.M., the surveyor observed and pointed out the grout disrepair and the holes in the grout around the drain. The surveyor asked the FSM if the garbage water was going into the sub flooring and she was observed to shrug and make the gesture she didn't know.At this time, the Surveyor observed the two black mats with the FSM and noted the mats were dirty and had dead cockroaches stuck to them. The FSM removed the top mat and live cockroaches and debris fell to the floor. The surveyor removed the second black mat from the heat booster, and additional live cockroaches fell to the ground with additional debris including dead cockroaches and what appeared to be cockroach egg sacs. The live cockroaches scurried under the dish machine and down into the cracks around the drain. At 3:50 P.M., the FSM went on to say that the staff do not use the mats anymore and said no they have not been cleaned. The FSM said she does not have a cleaning schedule for kitchen. During an interview on 5/7/26 at 8:45 A.M., the Maintenance Director and the FSM both said they do not have a maintenance logbook, they just communicate and text when there is a problem. During an interview on 5/7/26 at 8:50 A.M., Dietary Staff #3 said when the garbage disposal was broken for months it was like a dirty river of water across the dish room floor. Dietary Staff #3 said food would just come out at the bottom of the disposal. Dietary Staff #3 said we would push the water across the floor to the drain; it was a mess. During an interview on 5/7/26 at 12:25 P.M., the Consultant of PCC #2 said he did the consultation two weeks ago and said moisture and standing water are issues with pest control. The Consultant said he did identify significant issues with the pest control situation in the building and recommended they have him start a night spraying program. The Consultant viewed the picture of the debris that fell out of the black mats in the dish room and identified cockroach egg sacs. He said they are carried on the backs of cockroaches and then fall off and hatch. During an interview on 5/7/26 at 10:25 A.M., the Clinical Nurse and Administrator #2 (covering for the day) said they were aware of the cockroach problem in the kitchen, and they were working with a new pest control company. The Clinical Nurse said they were not aware of the concerns with the time it took to fix the garbage disposal and staff pushing the dirty drain water into the open drain, or the issues with holes in the grout in the dish room floor, or the leaking sinks. The Clinical Nurse said they were not aware the maintenance staff was spraying pesticides in the kitchen at night. Multiple staff members (housekeeping, nurses, certified nursing assistants, Dietary, and all three-unit managers) from the building's three units were interviewed regarding the ongoing cockroach problem in the building with the following responses: During an interview on 5/6/26 at 4:19 P.M., Unit Manager #3 said she saw cockroaches in the kitchenette on the unit. During an interview on 5/7/26 at 3:45 P.M., Dietary Staff #1 said she does see cockroaches moving around in the kitchen, usually by machines (pointing to the ice machine area). During an interview on 5/7/26 at 3:46 P.M., Dietary Staff #5 said he saw cockroaches in and around the ice machine and on the floor. During an interview on 5/11/26 at 1:23 P.M., Nurse #7 said she saw cockroaches at the nursing station and small baby cockroaches frozen in the ice from the kitchen.During an interview on 5/11/26 at 1:24 P.M., Unit Manager #1 said the night staff reports to her they see cockroaches in the kitchenettes. She said most of the cockroach sightings reported to her are in the food trucks. During an interview on 5/11/26 at 1:24 P.M., Certified Nursing Assistant (CNA) #9 said she has seen cockroaches very often on the food trucks when they are delivering food. During an interview on 5/11/26 at 1:31 P.M., CNA#3 said he has seen cockroaches on the food trucks; doesn't matter what meal it is. He said he also has seen them in the staff breakroom (located outside the main kitchen). CNA #3 said this has been going on for a long time and should have been fixed a long time ago. During an interview on 5/11/26 at 1:36 P.M., Housekeeper #1 said she has seen cockroaches when she cleans the kitchenettes. During an interview on 5/11/26 at 1:37 P.M., CNA #4 said she has seen cockroaches in the kitchenette and on the food carts that transport the coffee and snacks. CNA #4 said it has definitely gotten much worse in the last few months. During an interview on 5/11/26 at 1:41 P.M., Housekeeper #3 said she was aware of cockroaches in the staff break room and the kitchenettes. She said other housekeepers have sent pictures of cockroach sightings in the building to her. During an interview on 5/11/26 at 1:50 P.M., CNA #8 said she has seen cockroaches daily on the food trucks and kitchenettes. She said it is bad. During an interview on 5/11/26 at 1:54 P.M., CNA #6 said she has seen cockroaches on the food carts and said one staff member brought in cockroach plug-ins and round discs to help control the cockroaches at the nursing station on Unit #2. During an interview on 5/11/26 at 1:56 P.M., Nurse #5 said she has seen cockroaches on the food carts, crawling across residents' food, and she has heard of staff finding cockroaches frozen in the ice. Nurse #5 said there are no pest control sighting books until now. She said she would just tell the supervisor or a manager if she saw them. During an interview on 5/11/26 at 2:00 P.M., Unit Manager #2 said she has been told of cockroach sightings. She said there is no pest control sighting book until now. During an interview on 5/11/26 at 12:10 P.M., Administrator #3 said she thought the cockroach problem had gotten better since last summer. She said if she was notified of a cockroach problem in December 2025 she would have acted on it right away. She said she would have to do some research to see what was done because she went out on medical leave at the end of December. During an interview on 5/11/26 at 1:05 P.M., Administrator #2 said they did not have pest control sighting logbooks, but they do now. She said they closed the kitchen over the weekend to make repairs, and when they opened the walls, they found a couple cockroach nests. At the conclusion of the annual survey Pest Control Company #1 did not return the surveyor's phone call.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for two Controlled Substance Registers (controlled substance log books) reviewed out of six Controlled Substance Registers in use by the facility. Specifically, the facility failed:a. For Residents #139, #13, #120, #140 and #100, to ensure controlled substance registers have complete and accurate documentation upon the removal of narcotics that are discontinued from use, including all signatures required; andb. To ensure controlled substance disposal records were fully completed and maintained by the facility after the narcotics were destroyed, for accurate monitoring of destruction of narcotics.Findings include:Review of the facility's policy titled Management of Controlled Substances in Skilled Nursing Facilities, dated as revised October 2022, indicated but was not limited to the following:- The Controlled Substance Register is a bound book (with numbered pages), and has sections designated for an Index, Patient Pages, Prescription Inventory and Shift Count Pages.-The Administrator and DON must sign for the destruction in the medication destroyed box at the bottom of the patient page in the Controlled Substances Register and record the corresponding document and item number from the Controlled Substance Disposal Record.-Retain the completed Controlled Substance Disposal Record(s) for seven (7) years and/or in accordance with record retention policies.-The facility is responsible for retrieval of the disposal records for inspection. a. Review of the Controlled Substance Register numbered 2025-03 on Unit #1 Side 1 indicated the following:-Medication Destroyed section located on the bottom of each page number-Quantity destroyed-Document number-Item #-Date-Destroyed by-Two signatures -Resident #139-Controlled medication documented on page 77 for Temazepam 15 milligrams (mg) (hypnotic medication used to treat insomnia).-Two signatures indicated 36 capsules had been removed for disposal on 3/13/26.-Quantity on hand: 0 Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner of the page was incomplete. The section failed to include the quantity destroyed, document number, item number, date, or signatures of licensed staff destroying the medication. Resident #13-Controlled medication documented on page 103 for Oxycodone 5mg (opioid medication for pain).-Two signatures indicated 20 tablets had been removed for disposal on 4/26/26.-Quantity on hand: 0 Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner was incomplete. The section failed to include the quantity destroyed, document number, item number, date, or signatures of licensed staff destroying the medication. During an interview on 5/8/26 at 1:50 P.M., the surveyor reviewed her findings with Nurse #2. Nurse #2 said she signed the register when the medications were given to the Director of Nursing (DON) for removal. She said she does not destroy narcotics; she signs the register when she gives them to the DON or Assistant Director of Nursing (ADON) for removal. Review of the Controlled Substance Register numbered 2025-04 on Unit #1 Side 2 indicated the following: Resident #120-Controlled medication documented on page 13 for Ativan 0.5mg (antianxiety medication used to treat anxiety).-Two signatures indicated 12 tablets had been removed for disposal on 1/14/26.-Quantity on hand: 0 Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner was incomplete. The section failed to include the quantity destroyed, document number, item number, date or signatures of licensed staff destroying the medication. Resident #140-Controlled medication documented on page 52 for Oxycodone 5mg.-Two signatures indicated 11 tablets had been removed for disposal on 4/13/26.-Quantity on hand: 0 Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner was incomplete. The section failed to include the quantity destroyed, document number, item number, date or signatures of licensed staff destroying the medication. Resident #100-Controlled medication documented on page 113 for Morphine 20mg/milliliter (mL) (opioid medication used to treat pain).-Two signatures indicated 9ml had been removed for disposal on 4/28/26.-Quantity on hand: 0 Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner was incomplete. The section failed to include the quantity destroyed, document number, item number, date or signatures of licensed staff destroying the medication.Resident #100- Controlled medication logged on page 117 for Morphine 100mg/mL.- Two signatures indicated 30mL had been removed for disposal on 4/28/26.-Quantity on hand: 0Further review of the controlled substance register page indicated the medication destroyed section on the bottom right-hand corner was incomplete. The section failed to include the quantity destroyed, document number, item number, date or signatures of licensed staff destroying the medication. During an interview on 5/8/26 at 2:03 P.M., the ADON said the nurses tell her when a medication needs to be removed from the medication cart, and she also checks the carts monthly. She said the medications are taken to the DON or Administrator's office and destroyed. The ADON said they bring the register with them and complete the medication destroyed section at the time of destruction. The ADON said the registers are incomplete and missing documentation. She said the medication destroyed section is not filled out as it should have been. She said they also complete a medication destruction record for every narcotic that is destroyed. The surveyor requested to review the medication destruction records, including the destruction record for Resident #139. The ADON said she will locate them and provide them to the surveyor.b. Review of the document titled Controlled Substance Disposal Record in use by the facility, indicated the following information to be documented:-Name of Facility and address:-Document number-Date:-Item-Name of Patient-Name and strength of medication:-Prescription Number:-Physician:-Pharmacy:-Nurse's initials releasing medications:-Controlled substance book; include book and page number-Amount to be destroyed:-Drug actually destroyed:-Date destroyed:-Date of disposal:-Signature and license number of Director of Nursing:-Signature and license number of Administrator:Review of the completed Controlled Substance Disposal Records indicated the following:Document 2026-11 -Date: 4/24/2026-5 residents had controlled medications destroyed.-4 out of 5 residents had no strength of controlled medication.-5 out of 5 residents had no nurse initials releasing medications.-5 out of 5 residents had no controlled substance book number documented. Document 2026-7 -Date: 4/24/202610 residents had controlled medications destroyed.-10 out of 10 residents had no nurse initials releasing medications Document 2026-5 -Dated 2/2/26 and 3/6/26-6 residents had controlled medications destroyed.-6 out of 6 residents had no nurse initials releasing medications Document -No document number provided Date: 2/2/26-No facility name documented-12 residents had controlled medications destroyed-12 out of 12 residents had no documented nurse initials releasing medications-12 out of 12 residents had no documented name of drug actually destroyed.-12 out of 12 residents had no documented date destroyed.-12 out of 12 residents had no documented date of disposal.-Document failed to include license number of DON.-Document failed to include signature and license number of Administrator. Document 2026 Date: 2/2/26-5 residents had controlled medications destroyed.-5 out of 5 residents had no documented nurse initials releasing medications.-5 out of 5 residents had no documented drug actually destroyed.-5 out of 5 residents had no documented date of destruction.-No date of destruction-No second signature for destruction-Document failed to include signature and license number of Administrator. Document 2026-3 date: 1/14/26-2 residents had controlled medications destroyed.-Documented failed to include signature and license number of Administrator. Document 2026-2-Date: 1/14/26-9 residents had controlled medications destroyed.-1 out of 9 residents had no documented actual amount destroyed.-Document failed to include license numbers of DON and Administrator. Document 2025-16 date: 12/8/25-7 residents had controlled medications destroyed.-6 out of 7 residents had no documented controlled substance book number.-Documented failed to include signature and license number of Administrator. Document 2025-16 date: 10/6/25-8 residents had controlled medications destroyed.-4 out of 8 residents had no documented actual amount destroyed.No document provided to surveyor for destruction of medications for Resident #139 for date 3/13/26.During an interview on 5/11/26 at 10:32 A.M., the surveyor reviewed Register #2025-03 on Unit #1, side one for Resident #139 with Administrator #3. She said the medications were removed on 3/13/26 from the medication cart. She said she was unable to recall if she destroyed controlled medications on 3/13/26. She said there is no destruction record for that date to provide to the surveyor.During an interview on 5/11/26 at 1:48 P.M., the Consultant Pharmacist said he conducts medical record reviews for the facility, which include the controlled substance registers. He said he reviewed the registers on 5/9/26 and noted incomplete documentation for destruction of narcotics. He said he was given two file folders which contained the controlled substance disposal records to review as well. He said when narcotics are removed from use, it is required to have two signatures on the narcotic medication page in the medication destroyed section, and the destruction log must be filled out completely. The pharmacist said the destruction of narcotic documentation is incomplete. Pharmacist said he completed a written review of his findings and submitted it to the Administrator.Review of the Consultant Pharmacist report titled Consultant Pharmacist Monthly Unit Inspection Audit Report, dated 5/9/2026, indicated but was not limited to the following:- All 6 controlled substance registers were reviewed by pharmacist and recommendations requiring action are listed below:- Two signatures needed in Narcotic books for destruction of medications.- Destruction log for Resident #139 not found for controlled substance.

Based on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for one Resident (#143), out of a total sample of 25 residents. Specifically, the facility failed to ensure pharmacy medication labels were followed for Resident #143.Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.Review of the facility's policy titled Administration Procedure for all Medications, dated 9/20/13, indicated but was not limited to the following:-To administer medications in a safe and effective manner-Check Medication Administration Record (MAR) for order.-Read medication label three (3) times: 1) prior to removing the medication package/container from the cart/drawer; 2) prior to removing the medication from the package/container; 3) as the package/container is returned to the cart/drawer. Compare label to MAR.-After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or Treatment Administration Record (TAR).Resident #143 was admitted to the facility in April 2026 with diagnoses including chronic obstructive pulmonary disease (COPD) (lung disease that causes inflammation which causes difficulty breathing).Review of Resident #143's Physician's Orders indicated but were not limited to the following:-Breztri Aerophere Inhalation Aerosol (used to treat symptoms of COPD) 160-9-4.8 mcg/ACT (microgram per actuation), give 2 puff inhale orally, two times a day.Review of the Breztri inhaler medication label instructions from the pharmacy indicated:-Rinse mouth after useOn 5/7/26 at 8:28 A.M., the surveyor observed Nurse #3 prepare and administer medication to Resident #143. Nurse #3 administered Breztri inhaler to Resident #143 and failed to have the Resident rinse his/her mouth after inhaling the medication as indicated on the medication label from pharmacy.During an interview on 5/7/26 at 11:01 A.M., Nurse #3 said she should have had Resident #143 rinse his/her mouth after using the Breztri inhaler as indicated on medication label instructions and did not.During an interview on 5/7/26 at 11:03 A.M., the Staff Development Coordinator (SDC) said Nurse #3 should have followed the medication instructions by reading both the MAR for instructions and the label on the medication to be sure the prescribed medication was administered correctly.During an interview on 5/7/26 at 11:05 A.M., Unit Manager #1 said the medication should have been administered correctly.During an interview on 5/11/26 at 9:27 A.M., the Assistant Director of Nursing (ADON) said the nurse should have followed the medication label instructions for rinsing the Resident's mouth after using a steroid inhaler and that was not done.

Based on observation, record review, and interview, the facility failed to ensure staff notified the physician in a timely manner of a recommendation for a medication change from the consulting Psychiatric Nurse Practitioner (PNP) for one Resident (#116), out of a total sample of 25 residents. Specifically, the facility failed to notify the physician of the PNP's recommendations to decrease Cymbalta (an antidepressant medication) from 60 milligrams (mg) to 30 mg and add Zoloft (an antidepressant medication) 25 mg due to depression. Findings include:Review of the facility's policy titled Consultant Recommendations and Physician Orders, dated as revised February 2024, indicated but was not limited to the following: -The nurse will notify the attending physician of findings and recommendations for med changes or further orders. The notification should be immediate if consultant findings and recommendations indicate need for med or treatment order changes. Resident #116 was admitted to the facility in April 2026 with diagnoses of depression and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 4/5/25, indicated Resident #116 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired and was receiving antidepressant medication. Review of the Physician's Orders indicated but was not limited to the following: -Cymbalta 60mg 1 capsule by mouth everyday start date 4/29/26 -Psych consult as needed start date 4/30/26 Review of the PNP's progress note, dated 5/1/26, indicated but was not limited to the following: -Chief complaint: Depression -Severity: Moderate -Mood: Depressed -Recommendations: Mood: Decrease Cymbalta from 60mg to 30mg daily. Sad mood. Consider adding Zoloft 25mg by mouth daily. -PNP is in a consultative role; recommendations are given to facility prescriber. -Recommend gradual dose reduction (GDR) with taper for discontinuation of Cymbalta as it appears ineffective at managing depressive symptoms. GDR recommended follow-up 2-4 weeks. Review of the physician, NP, and nursing progress notes failed to indicate the recommendation had been communicated to the provider. During an interview on 5/7/26 at 11:50 A.M., Resident #116 said he/she was very weepy and sad. During an interview on 5/7/26 at 12:35 P.M., Social Worker # 1 said Resident #116 had been experiencing increased weepiness and had placed a referral to the PNP to assess the Resident and make recommendations if needed. During an interview on 5/7/26 at 2:29 P.M., Unit Manager (UM) #1 said the PNP recommendations were sent to her via email. UM #1 said she is supposed to print the recommendations and review them with the provider. She said she missed it and did not inform the provider of the new recommendations.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of four nurses observed during the medication pass made two errors out of 30 opportunities, resulting in a medication error rate of 6.67%. Those errors impacted two Residents (#143 and #49).Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated and revised April 11, 2018, indicated but was not limited to the following: Nurses Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.Review of the facility's policy titled Administration Procedure for all Medications, dated 9/20/13, indicated but was not limited to the following:-To administer medications in a safe and effective manner-Secure records containing protected health information, (e.g., Medication Administration Records (MARs) and Treatment Administration Records (TARs).-Check MAR for order.-Read medication label three (3) times: 1) prior to removing the medication package/container from the cart/drawer; 2) prior to removing the medication from the package/container; 3) as the package/container is returned to the cart/drawer. Compare label to MAR.-After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or TAR.a. Resident #143 was admitted to the facility in April 2026 with diagnoses including rheumatoid arthritis (autoimmune disease which causes painful swelling and stiffness) and chronic obstructive pulmonary disease (COPD) (lung disease that causes inflammation which causes difficulty breathing).Review of Resident #143's Physician's Orders indicated but were not limited to the following:-Hydroxychloroquine sulfate (used to treat symptoms of rheumatoid arthritis) 200 milligrams (mg), give one and a half tablets by mouth for a total dose of 300mg.On 5/7/26 at 8:28 A.M., the surveyor observed Nurse #3 prepare and administer medication to Resident #143. Nurse #3 administered hydroxychloroquine sulfate 100mg one and a half tablets (totaling 150mg) with Resident #143's other morning medications. During an interview on 5/7/26 at 11:01 A.M., Nurse #3 said she administered the wrong dose of Hydroxychloroquine sulfate medication to Resident #143. Nurse #3 said she administered 150mg instead of the physician prescribed dose of 300mg. Nurse #3 said she should have followed the instructions and read both the MAR and blister pack medication instructions. During an interview on 5/7/26 at 11:03 A.M., the Staff Development Coordinator said Nurse #3 should have followed the medication instructions by reading both the medication administration record (MAR) for instructions and the label on the medication to be sure the prescribed medication was administered correctly.During an interview on 5/7/26 at 11:05 A.M., Unit Manager #1 said the medication order should have been followed.During an interview on 5/11/26 at 9:27 A.M., the Assistant Director of Nursing (ADON) said the nurse should have followed the medication order as prescribed and checked the MAR and label on the medication for accuracy.b. Resident #49 was admitted to the facility in March 2024, with diagnoses including type 2 diabetes mellitus with ketoacidosis (diabetes with high levels of ketone byproducts created by the liver breaking down fat for energy).Review of Resident #49's Physician's Orders indicated but were not limited to the following:-Lantus Solostar (used to treat diabetes) 100 unit/milliliter (U/ml) insulin pen, inject 18 unit subcutaneously in the morning (4/2/26)-pen needle, 30 gauge x 3/16, 1 pen needle miscellaneous as needed for insulin pens. Attach to insulin pen for administration. On 5/7/25 at 8:12 A.M., the surveyor observed Nurse #4 dial Resident #49's Lantus Solostar 100unit/mL (milliliter) insulin pen to 18 units, apply the needle tip to the insulin pen, and administer the insulin to Resident #49. Nurse #4 failed to prime the needle chamber to fill it with insulin prior to administering the Resident's insulin. Review of manufacturer instructions for use of Lantus Solostar (Lantus) insulin pre-filled pen manufactured by Sanofi-Aventis, revised May 2025, indicated but was not limited to the following:-Step 3: Do a safety test:-Section 3A: Select 2 units by turning the dose selector until the dose pointer is at the 2 mark.-Section 3B: Press the injection button all the way in, when insulin comes out of the needle tip, your pen is working correctly.-If no insulin appears: you may repeat this step up to 3 times before seeing insulin.-If no insulin comes out after the third time, the needle may be blocked. If this happens: change the needle; then repeat the safety test.-Always perform the safety test before each injection.During an interview on 5/7/26 at 11:21 A.M., Nurse #4 said she has been administering insulin pens for a long time and her process is to dial the pen to the prescribed dose, attach the needle, then administer the medication to the resident. Nurse #4 said she did not prime the insulin pen or check the pen to ensure it was working correctly. The surveyor and Nurse #4 reviewed the manufacturer instructions for safe administration of insulin pens. Nurse #4 said she did not follow the steps as indicated on manufacturer instructions and said she has never primed an insulin pen.During an interview on 5/7/26 at 11:24 A.M., Unit Manager UM #3 said her understanding of insulin pens process is to dial the pen to prescribe dose, attach the needle tip, and administer the insulin medication. The surveyor and UM #3 reviewed manufacturer instructions for safe administration of insulin pen, UM #3 said she was not aware of those steps for insulin pen administration.During an interview on 5/7/26 at 12:02 P.M., the Staff Development Coordinator (SDC) said she has never educated the nurses to prime an insulin pen and was not aware of the manufacturer safety instructions for priming the insulin pen to ensure the pen and needle tip were working. The SDC said a nursing student told her quite a while ago that insulin pens need to be primed with 1-2 units of insulin to be sure it is not clogged and resident is getting the correct dose and said she has never educated the nurses on this step. The surveyor and the SDC reviewed manufacturer instructions for safe insulin administration, and the SDC said the nurses should be following the manufacturer guidelines for insulin pen administration and this has not been done. During an interview on 5/11/26 at 9:27 A.M., the Assistant Director of Nursing (ADON) said the nurse should have followed the manufacturer's instructions for insulin pen administration. The ADON said the nurse should have primed the insulin pen before administering the insulin.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure staff followed hand hygiene procedures prior to handling medication(s) and after administering medication(s) and that staff handled medications in a sanitary manner to prevent potential transmission of infections.Findings include:Review of facility's policy titled Administration Procedure for all Medications, dated 9/20/13, indicated but was not limited to the following:-Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident.-Use a barrier (e.g. clean disposable tray or plastic cup) to carry medication containers into the resident's room, this will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are placed while the medication is administered.-When finished with each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer.On 5/7/26 from 8:28 A.M. through 9:07 A.M., the surveyor observed Nurse #3 administer medications to Resident #143. Nurse #3 failed to perform hand hygiene before and after administering medications. The surveyor observed Nurse #3 touching the computer, the medication room door, her phone, the treatment storage cart, the medication packages, and the medication cart drawer handles between handling the Resident's medications, potentially contaminating her hands. Furthermore, the surveyor observed Nurse #3 remove Breztri inhaler (used to treat symptoms of COPD), and Flonase nasal spray (used to treat allergy symptoms), from prescription packaging and place them directly onto Resident #143's bedside table for administration without a protective barrier. After administration of medications to Resident #143, Nurse #3 placed the Breztri inhaler and Flonase nasal spray directly onto the medication cart without a protective barrier. Nurse #3 then placed the inhaler back and nasal spray back into the medication cart without performing hand hygiene.During an interview on 5/7/26 at 9:07 A.M., Nurse #3 said she should have performed hand hygiene before starting the medication pass, after touching the medication doors, the treatment cart, her phone, and after medication pass was completed and did not. Nurse #3 said she performs hand hygiene when she remembers. Nurse #3 said she should not have placed the inhaler and nasal spray on Resident #143's bedside table without a protective barrier and should not have then placed the inhaler and nasal spray directly onto the medication cart without a protective barrier.During an interview on 5/7/26 at 11:05 A.M., Unit Manager #1 said the nurse should have performed hand hygiene prior to, during, and after the medication pass and should have used a protective barrier with medications brought into the Resident's room.During an interview on 5/11/26 at 9:27 A.M., the Assistant Director of Nursing (ADON), said the nurse should have performed hand hygiene at the start of medication pass, at any opportunity hand hygiene was indicated during the medication pass, and at the end of the medication pass. The ADON said the nurse should have placed a protective barrier down when the inhaler and nasal spray were placed on the Resident's bedside table and on the medication cart.

Based on record review, observations, and interviews, the facility failed to ensure a resident with an alteration in skin integrity related to a wound, specifically moisture associated skin damage (MASD), received necessary treatment and services in accordance with professional standards of practice to promote healing for one Resident (#129), out of a total sample of 25 residents. Specifically, the facility failed to transcribe and implement recommendations from the Wound Care Consultant for one month and ensure a pressure relieving air mattress was inflated properly. Findings Include:Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:- Advisory: It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires such order in accordance with accepted standards of practice and in compliance with the Board's regulations.- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Consultant - Recommendations and Physician Orders, dated as last revised February 2024, indicated but was not limited to the following:- Findings and recommendations will be documented on the Consultation, and the Consultation will be delivered to the nurse responsible for the patient immediately following the consultation.- The nurse will notify the attending physician of findings and recommendations for med changes or further orders. The notification should be immediate if consultant findings and recommendations indicate need for med or treatment order changes.- The nurse will notify the appropriate interdisciplinary team members of need for follow through on the consultant findings/recommendations.- The attending physician, if in agreement, will order the specific treatments or medications as outlined by the consultant.- The nurse will transcribe the orders, update the care plan and resident Kardex as indicated, and communicate changes in nursing report and nursing note. Resident #129 was admitted to the facility in September of 2024 with diagnoses which included traumatic brain injury and legal blindness. Review of the Minimum Data Set (MDS) Assessment, dated 3/6/2026, indicated Resident #129 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairments. Additionally, the MDS indicated Resident #129 was dependent on staff assistance for all Activities of Daily Living (ADLs) except eating for which Resident #129 required set-up assistance, and dependent on staff assistance for all mobility. Review of the Physician Orders for Resident #129 indicated but was not limited to the following:- Alternating pressure mattress overlay. Ensure inflation and correct settings q shift. Setting at 4 based on weight and manufacturers recommendations. Start Date: 4/6/2026- Vitamin A and D Ointment (topical skin protectant made from petrolatum and added vitamins to support healing); Apply to buttocks topically two times a day for Rash AND every 24 hours as needed for Rash. Start Date: 4/7/2026 Review of Nursing Progress Notes for Resident #129 indicated but was not limited to the following:- On 4/6/2026: air mattress applied to resident's bed for skin breakdown prevention and comfort due to immobility and incontinence. Review of the Wound Care Consultant Progress Notes indicated but was not limited to the following:- Resident was seen by the Wound Care Consultant on 4/8/2026. Resident was referred by Nurse Practitioner (NP) #1 and floor nursing staff for a wound to the buttocks, present not less than 1 day. The wound is currently treated with Vitamin A&D ointment. The wound is described as: moderately irritated erythematous (reddened) flaky skin overlying well-circumscribed area of chronic skin changes and notable area of raised hypertrophic scar tissue (abnormal healing, raised red or brown scar tissue) of the left buttocks, scant serosanguinous exudate (thin and watery drainage with a pink-red hue) with scattered small areas of denuded raw open skin, no periwound erythema (redness) or induration (localized area of firm, dense tissue), mild episodic tenderness. Wound measurement: 10 X 12 cm. The plan indicates: Discontinue A&D ointment to wound of buttocks; Apply Triad hydrophilic wound paste (zinc oxide-based dressing ointment designed to manage low to moderate levels of wound drainage while promoting a moist healing environment) to wound of buttocks daily and as needed; Request nutritionist assessment and supplementation as indicated to support wound healing and skin integrity health; Follow-up with Wound MD in 1 week.- Resident was seen by the Wound Care Consultant on 4/15/2026. Resident was seen in follow-up for the wound to the buttocks. The wound is described as: minimally irritated erythematous flaky skin overlying well-circumscribed area of chronic skin changes and notable area of raised hypertrophic scar tissue of the left buttock, no exudate, open or denuded areas of skin, no periwound erythema or induration, mild episodic tenderness. Wound measurement: 10 X 10 cm. The plan indicates: Continue Triad hydrophilic wound paste to wound of buttocks daily and as needed X 7 days. Continue nutritionist assessment and supplementation as indicated to support wound healing and skin integrity health; Follow-up with Wound MD as needed. Review of the Nursing Advances - Skin Check Assessments for Resident #129 indicated but was not limited to the following:- 4/14/2026: Skin Issues: Skin Issue: #001: New skin Issue. Location: Left gluteus. Laterality/Orientation: Left. Additional location information: left buttocks. Issue type: Moisture associated skin damage (MASD). Progress: Stable: previously deteriorating wound characteristics plateaued. MASD: IAD Incontinence Associated Dermatitis. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: N/A. Length (cm): 10 Width (cm): 12 Depth (cm): 0 Undermining: No. Tunneling: No. Exudate amount: Light. Exudate type: Serosanguinous: mixture of serous and sanguinous fluid, typically pale, red, and watery. Odor after cleansing: None. Other wound bed: none. Periwound: Attached. Surrounding tissue: Dry/flaky. Surrounding tissue: Erythema. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Review of Provider Progress Notes for Resident #129 failed to mention any wound or treatment following the Wound Care Consultation on 4/8/2026. Review of the electronic medical record including Assessments and Progress Notes for Resident #129 failed to indicate a nutritional assessment was completed following the Wound Care Consultation on 4/8/2026. Review of the Treatment Administration Record for Resident #129 for the month of April 2026 indicated but was not limited to the following:- The order for the pressure-relieving air mattress was signed off every shift beginning on 4/6/2026 through 4/30/2026.- The order for Vitamin A&D ointment was signed off at 10 A.M. and 4 P.M. every day, beginning on 4/7/2026 through 4/30/2026. Review of the Treatment Administration Record for Resident #129 for the month of May 2026 indicated but was not limited to the following:- The order for the pressure-relieving air mattress was signed off every shift beginning 5/1/2026 through 5/7/2026 day shift except on 5/5/2026 night shift when documentation was missed.- The order for Vitamin A&D ointment was signed off at 10 A.M. and 4 P.M. every day, beginning on 5/1/2026 through 5/7/2026 at 10 A.M. except on 5/3/2026 at 10 A.M. when documentation was missed. Review of the Comprehensive Care Plan for Resident #129 indicated but was not limited to the following: The resident needs alternating pressure mattress to bed setting by resident's weight to #4. Initiated 4/6/2026. On 5/5/2026 at 9:04 A.M. and on 5/6/2026 at 7:45 A.M., the surveyor observed Resident #129 lying in bed with a pressure-relieving air mattress and pump in place but not on or functioning and the surveyor could feel the hard, metal bed frame through the deflated air mattress. On 5/6/2026 at 8:37 A.M. during an observation and interview with Certified Nursing Assistant (CNA) #2, Resident #129 was lying in bed with a pressure-relieving air mattress and pump in place but not on or functioning. CNA #2 confirmed that he could feel that the air mattress was deflated. CNA #2 said he thinks that the air mattress should be on and he wanted to confirm with Resident #129's nurse. On 5/6/2026 at 8:42 A.M. during an observation and interview with Nurse #4, Resident #129 was lying in bed with a pressure-relieving air mattress and pump in place but not on or functioning. Nurse #4 confirmed that the air mattress pump was not on and said it should be on. Nurse #4 tried to turn on the air mattress pump by pressing the buttons on the pump, but it did not turn on. Nurse #4 said she would try to troubleshoot and then she would call maintenance if she could not get it to turn on. Nurse #4 checked the electrical cord for the air mattress pump and determined it was not plugged in. Nurse #4 plugged the electrical cord for the air mattress pump into the wall and the air mattress turned on and began to inflate. Nurse #4 said that the process for pressure-relieving air mattresses is to check and confirm they are working every shift and sign off the check in the electronic medical record. Nurse #4 said she had not been to Resident #129's room yet to check the air mattress. During an interview on 5/6/2026 at 8:47 A.M., Unit Manager #3 said all pressure-relieving air mattresses should be on and functioning per physician's order. Unit Manager #3 said the process is for all pressure-relieving air mattresses to be checked by the nurse every shift to confirm they are working, and for the nurse to sign off this check in the electronic medical record. During an interview on 5/6/2026 at 12:51 P.M., Nurse #4 said the process for the Wound Care Consultant is that she rounds with the Assistant Director of Nurses (ADON) on Wednesday mornings and then the ADON enters the recommendations as orders. Nurse #4 said she just does the treatments as they are ordered. During an interview on 5/6/2026 at 12:58 P.M., the ADON said she rounds every Wednesday with the Wound Care Consultant. The ADON said after the consultations, she enters the recommendations as orders. The ADON said she does not generally review the orders with the resident's provider prior to entering the orders unless it is something odd as the provider generally agrees with all of the recommendations from the Wound Care Consultant. The ADON said she would expect the recommendations that were made during the visit with the Wound Care Consultant on 4/8/2026 to have been entered as orders including the application of Triad hydrophilic paste daily and the need for a nutritional assessment. During an interview on 5/6/2026 at 1:14 P.M., Nurse #4 said she has never seen an order for Triad hydrophilic paste for Resident #129. During an interview on 5/6/2026 at 1:38 P.M., NP #1 said residents are seen routinely by the Wound Care Consultant on Wednesday mornings. NP #1 said that he knows the Wound Care Consultant well and trusts her assessments and recommendations. NP #1 said he has never not agreed with her recommendations. NP #1 said that he usually comes in later on Wednesday mornings and the ADON or unit manager will run the recommendations from the Wound Care Consultant by him.

Based on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment for the residents residing on two units (Units 2 and 3) out of three units. Findings include: On 1/22/25 at 9:30 A.M., on Unit 2, the surveyor made the following observations: -Hallway: Broken tray table; door had a metal strip peeling away from wood (separated approximately 4 inches); and outside of room [ROOM NUMBER], a broken dial thermostat with wires exposed. -Main Dining Area: Stained and sagging ceiling tiles (approximately 10); a hole approximately 5 inches tall with a crack that expanded 12 inches high in the wall. There was loose plaster surrounding the hole above the slotted heat vent. -Three Stairwell Doors had brown-stained Velcro stop sign banners with varying sizes of stains covering the sign. -Kitchenette: The top of the microwave was bubbled and had metal flakes peeling away from it. -room [ROOM NUMBER]: Missing closet doors -room [ROOM NUMBER]: Broken blinds -room [ROOM NUMBER]: Cracked floor tiles -room [ROOM NUMBER]: Missing closet doors -room [ROOM NUMBER]: Broken tray table; Threshold to the room had missing floor tiles with exposed flooring leaving approximately a one-inch-deep gap between carpeting in hallway and tile in the room; Scrapes and scuffs on walls. -room [ROOM NUMBER]: Scrapes and scuffs on walls During an interview on 1/23/25 at 4:20 P.M., the Maintenance Director said this unit can be harder to identify issues with since the residents can't tell us when things are broken. He said he does round but has missed the concerns the surveyor identified. He said he prioritizes repairs based on safety rather than aesthetics. During an interview on 1/23/25 at 4:30 P.M., the Administrator said she agrees and is aware the unit needs a lot of work and repairs. The expectation is the environment is clean and in good repair to create a homelike environment for the residents. She said all the items that were broken need to be repaired. She said that it is a large building and can be difficult to keep up with routine things like paint, walls, and repairs. She said the Maintenance department focuses on safety concerns and there is not much time for routine maintenance. She said there should be a better process in place for identifying these concerns. 49428 On 1/22/25 through 1/24/25, the surveyor oberved that room [ROOM NUMBER], on Unit 3, had a fabric covered, wooden-framed chair, with severely worn fabric at the seat area, especially the front center and right hand portions. The wooden arms were scratched/scraped and revealed the bare wood underneath. The chair was facility owned and intended for visitor use. During an interview on 1/23/25 at 12:20 P.M., Nurse #2 said that the chair was extremely worn and should be replaced.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in Resident #124's room. Findings include: Review of the facility's policy titled Storage of Medications, revised 6/10/22, indicated the following: -Purpose: medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel -medication supplies are locked or attended by persons with authorized access Resident #124 was admitted to the facility in October 2024 following a fracture of the right hip. Review of the Minimum Data Set (MDS) assessment, dated 11/3/24, indicated Resident #124 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During an interview with observation on 1/22/25 at 8:40 A.M., Resident #124 said he/she had pain and the staff had been putting a white patch on his/her back. At this time, the surveyor observed two packages of Lidocaine Patch 5% (used to relieve pain) on the nightstand next to Resident #124's bed. One of the packages had been cut open and contained a white patch and the other package was closed. On 1/23/25 at 12:38 P.M., the surveyor observed the same two packages of Lidocaine Patch 5% on the nightstand next to Resident #124's bed. Review of the medical record indicated Resident #124 had a physician's order for Lidocaine Patch to be applied every morning at 9:00 A.M. and removed at 8:00 P.M. Review of the Self-Administration of Meds (medications) form, dated 10/29/24, indicated Resident #124 did not wish to administer their own medications. During an interview on 1/23/25 at 12:42 P.M., Nurse #1 reviewed the medical record and confirmed Resident #124 had an order for a Lidocaine Patch. She said she had administered medications to the Resident this morning and had not noticed the open and unopened Lidocaine Patches on the nightstand. She said the patches should not have been left in the Resident's room. During an interview on 1/23/25 at 2:10 P.M., the Infection Control Preventionist said the patches should not have been left at the bedside and the nurses entering the Resident's room should have noticed they were on the nightstand.

Based on observation, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable disease and infection, for two Residents (#76 and #105), of a total sample of 24 sampled residents. Specifically, the facility failed: 1. For Resident #76, to ensure the Resident's respiratory equipment was maintained in a safe, clean and sanitary condition; and 2. For Resident #105, to ensure proper infection control measures, specifically handwashing, were implemented during a gastrostomy tube dressing change. Findings include: 1. Review of the facility's policy titled Clinical Policy and Procedure Manual, undated, indicated but was not limited to: 14. Replace entire set-up every seven days. Date and store in treatment bag when not in use. Resident #76 was admitted to the facility in June 2022 with diagnoses which included malignant neoplasm of the right bronchus or lung and acute respiratory failure with hypoxia. Further record review indicated that the Resident was undergoing chemotherapy treatments for lung cancer which lowers the immune system placing the Resident at increased risk of infection. According to the American Cancer Society, May 1, 2020, patients who undergo chemotherapy have the potential side effect of infection. Review of Resident #76's Physician's Orders indicated: -Oxygen, 0-4 liters per minute via nasal cannula to maintain an oxygen saturation rate of 88%, via an oxygen concentrator. On 1/22/25 at 9:07 A.M., the surveyor observed Resident #76's nasal cannula lying directly on the soiled/stained bed and not contained in a bag per the facility policy. The oxygen concentrator was running at 2.5 liters; however, the Resident was not in the room at that time. On 1/24/25 at 8:08 A.M., the surveyor observed Resident #76's nasal cannula laying on the unmade bed, the nebulizer mask on top of the nightstand, not contained in a bag per the facility policy, and the incentive spirometer laying on the stained floor with the mouthpiece touching the floor. During an interview on 1/28/25 at 12:30 P.M., the Director of Nursing (DON) said that respiratory equipment/ Oxygen tubing should go in a bag at the bedside when not being worn. The DON said that the Resident may have left it on the bed himself/herself but it should be stored in the bag. An Incentive Spirometer is usually stored on the bedside not on the floor. The DON said that nursing needs to make sure that respiratory equipment is stored properly in accordance with their policy, in order to prevent contamination. 2. Review of Lippincott Nursing Procedures, 9th Ed. (2023), Enteral Gastrostomy and Jejostomy Tubefeeding and Care, the following procedures for changing a gastrostomy tube dressing are to be followed: For site care -Perform hand hygiene. -Put on gloves to comply with standard precautions. -Gently remove the dressing to prevent skin stripping or tearing and discard it in an appropriate receptacle.19,34 Don't cut away the dressing over the catheter, because you might cut the tube or the sutures holding the tube in place. -Remove and discard your gloves. -Perform hand hygiene. -Put on a new pair of gloves. Resident #105 was admitted to the facility in October 2023. Review of the medical record indicated that the Resident had a gastrostomy tube for all nutrition and hydration, and treatment to the gastrostomy tube was provided by nursing daily. On 1/23/25 at 12:15 P.M., the surveyor observed Nurse #2 perform the dressing change to the Resident's gastrostomy tube. Nurse #2 sanitized her hands and donned non-sterile gloves. Nurse #2 then removed the soiled drain sponge containing a moderate amount of tan drainage and disposed of it in the trash. She then proceeded to don (apply) a new pair of gloves without sanitizing her hands. She then proceeded to clean around the gastrostomy tube with dermal cleanser, patted the area dry with 4x4 gauze, applied bacitracin ointment around the gastrostomy tube, and taped a drain sponge in place around the gastrostomy tube. During an interview on 1/23/25 at 12:20 P.M., Nurse #2 said that she should have sanitized, or washed her hands, after removing the soiled drain sponge, prior to donning clean gloves to perform the treatment to the Resident's gastrostomy tube. During an interview on 1/28/25 at 10:45 A.M., the DON said that it is her expectation that the nurse use alcohol-based hand rub or wash her hands after removing the soiled dressing/gloves and before donning new, clean gloves.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the facility failed to ensure he/she was free from physical and sexual abuse by another resident. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of and between the legs of Resident #1 who had no clothes on. Resident #2 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. The residents were immediately separated by staff. A short time prior to being found together in bed, a staff member (later identified as CNA #1) had observed Resident #2 sitting next to Resident #1 in the hallway and observed Resident #2 stroking Resident #1's arm, and although the staff member said she thought it was yucky to see Resident #2 touching Resident #1 because of Resident #2's history of sexually inappropriate behaviors, she did not separate them and continued on with her work assignment. Resident #1, was so visibly shaken by the sexual assault that he/she was unable to ambulate and required the use of a wheelchair so staff could transport him/her back to his/her own room. Resident #1 complained of pain in his/her genital/pelvic area, with blood and discharge also observed in that same area. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she also complained of head, leg and knee pain. Resident #1 also underwent a Sexual Assault Nurse Exam (SANE) (forensic nursing care to victims of sexual assault which included a forensic physical examination and evidence collection, documentation of assault and physical findings, medication management, crisis intervention, discharge planning and referrals). Family Member #1 said Resident #1 was flipping out and crying in the ED, needed to be sedated, has experienced night terrors and exhibiting adverse behaviors towards caregivers with attempts to provide him/her with care, since the sexual assault. Findings include: The Facility Policy titled Resident Abuse Prevention, Investigation and Reporting, most recently revised 2/17/17, indicated that it was the Policy of the Facility for all staff to ensure an environment free of abuse. The Policy defined abuse as the willful infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The Policy defined sexual abuse as sexual harassment, sexual coercion or sexual assault. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident to resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of the Police Report, dated 11/19/23 indicated that police officers were dispatched to the Facility at 1:50 P.M. after a sexual offense occurred on the Alzheimer's/Dementia Unit. During a telephone interview on 12/03/23 at 10:20 A.M., Family Member #1 said that on 11/19/23, a Facility staff member called her and reported that Resident #1 and Resident #2 had been found having sexual intercourse. Family Member #1 said staff told her Resident #1 was totally naked in Resident #2's room. Family Member #1 said that the Facility staff member told her that Resident #2 had also been naked and had been on top of Resident #1 thrusting his/her genital area against Resident #1's genital area. Family Member #1 said that she was flabbergasted. Family Member #1 said that Facility staff members (exact names unknown) told her that Resident #2 was a new resident and that they did not really know what his/her behaviors were. Family Member #1 said that she had been Resident #1's primary caregiver for three years prior to his/her admission to the Facility and was his/her Health Care Agent. Family Member #1 said that Resident #1 had not been sexually active for many years and said he/she never exhibited any sexual interest or sexually inappropriate behaviors while she was caring for him/her. Family Member #1 said Facility staff members had never reported to her that Resident #1 exhibited any sexual interest or sexually inappropriate behaviors while he/she had resided at the Facility. Family Member #1 said that when she arrived at the Hospital where Resident #1 had been transferred, Resident #1 was with the police, a sexual assault advocacy social worker and the hospital social worker. Family Member #1 said that Resident #1 was flipping out, crying and raging. Family Member #1 said that Resident #1 had to be sedated in the emergency room and hospital staff were comforting Resident #1. Family Member #1 said that Resident #1 complained of pain in his/her body from Resident #2's weight (body) being on top of him/her. Family Member #1 said that Resident #1 stayed in the emergency department for two days while the hospital arranged for him/her to be placed in different long-term care facility. Family Member #1 said that, since the sexual assault, Resident #1 has experienced night terrors during which he/she stood up to get away and had fallen. Family Member #1 also said that Resident #1 has been resisting care, swearing at staff members and being difficult which were behaviors he/she had not exhibited prior to the sexual assault. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors, he/she required extensive assistance with dressing and his/her health care proxy had been activated. The MDS indicated Resident #1 was 5'3 tall and weighed 147 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #1's review of systems indicated he/she experienced anxiety, dementia, depression, was a limited historian and confused at baseline. The Report indicated Resident #1 was easy to engage and when asked how he/she was feeling stated, Oh, I am so happy, I love you. The Report indicated the plan was to continue to monitor Resident #1's mood, behavior and safety. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #1 several times during his/her stay at the Facility and that Resident #1 was pleasant, social, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #1's judgement and decision-making were impaired, and he/she could not consent to sexual activity. Review of Resident #2's Admission MDS Assessment, dated 10/22/23, indicated that he/she had been admitted to the Facility during October 2023, his/her cognitive patterns were severely impaired, he/she wandered daily and his/her health care proxy had been activated. The MDS indicated Resident #2 was 5'2 tall and weighed 178 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #2's past medical history included adjustment disorder with mixed disturbance of emotions and conduct, dementia, anxiety and delusional disorder. The Report indicated Resident #2 had a history of exit seeking, agitation, pacing, verbal aggression, yelling and he/she often got out of bed at night and wandered. The Report indicated Resident #2 was a limited historian and confused at baseline. The Report indicated Resident #2 had a significant history of trauma, with a history of unsafe behaviors, agitation, and verbal aggression. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #2 twice during his/her stay at the Facility and that Resident #2 was confused, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #2 had a significant trauma history and was very focused on a previous female companion during her initial assessment meeting with him/her. The Psychiatric Nurse Practitioner said Resident #2's judgement and decision-making were impaired and he/she could not consent to sexual activity. Review of Resident #2's pre-admission Referral Paperwork, provided to the surveyor by the Admission Director, which included documented information from the hospital stay which preceded Resident #2's Facility Admission, indicated that Resident #2 had a history of violence toward others and per reports, attempted to choke his/her significant other. During an interview on 11/22/23 at 10:00 A.M., the Admission Director said that she had not read (missed it during her review) the information on Resident #2's Referral Paperwork which indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The Admission Director said that although the screening liaison could have offered a bed at the Facility for Resident #2 with his/her history, she should have seen the information on the referral and made sure the interdisciplinary team was aware of his/her history. During an interview on 11/22/23 at 10:30 A.M. Certified Nurse Aide (CNA) #1 said that on 11/19/23, the day she witnessed what she thought was Resident #2 having sex with Resident #1, said that although she was not assigned to care for either one of them that day, said that sometime between 12:00 P.M. and 1:00 P.M., she observed Resident #1 and Resident #2 sitting together outside of the dining area across from the nursing station. CNA #1 said that she saw Resident #2 rubbing Resident #1's arm and thought to herself yuck because of Resident #2's history of sexually inappropriate behaviors. CNA #1 said she did not separate Resident #1 and Resident #2 and continued with her other duties. CNA #1 said that CNA #7 had previously told her about an incident that had occurred while Resident #2 resided on the first-floor unit, during which Resident #2 pulled her (CNA #7's) shirt collar down to see CNA #7's breasts. During an interview on 11/22/23 at 11:55 A.M., CNA #7 said that she provided one or two showers to Resident #2 while he/she was on the first-floor unit (unit where Resident #2 had resided between 10/18/23 and 11/13/23). CNA #7 said that during one shower, Resident #2 pulled her shirt collar away from her chest and looked down her shirt. CNA #7 said that when she told Resident #2 that he/she could not do that, Resident #2 stated, you can have me here naked and I can't take a peek at your boobs? CNA #7 said she reported the incident with Resident #2 to Unit Manager #1. CNA #1 also said that Resident #3 (who resided on the first-floor unit were Resident #2 had previously resided) told her (exact date unknown but knows it was prior to Resident #2's transfer to the dementia unit) that Resident #2 asked him/her when they were going to go to bed together, and that Resident #3 had also told her he/she was afraid of Resident #2. During an interview on 11/22/23 at 11:40 A.M., Resident #3 (who resides on the first floor Unit) said that Resident #2 came into his/her room and stated, are you going to stand there or are you going to come to bed with me? Resident #3 said Resident #2 said they could get into either one of their beds. Resident #3 said that he/she told Resident #2 no and to leave his/her room or he/she would call the police and said that Resident #2 had gotten mad at him/her. Resident #3 said that after the incident, he/she felt afraid that Resident #2 would try to crawl into his/her bed while he/she was sleeping. Resident #3 said that she reported the incident to staff members. During an interview on 11/22/23 at 1:53 P.M., Unit Manager #1 said that she was the unit manager on the first-floor Unit where Resident #2 resided from 10/18/23 to 11/13/23. Unit Manager #1 said that at the time of Resident #2's transfer to the second floor Unit, she was not aware of Resident #2's sexually inappropriate behaviors including the incidents in which he/she looked down CNA #7's shirt and asked Resident #3 when they were going to go to bed together. During a telephone interview on 11/30/23 at 9:45 A.M. with Nurse #5, and a telephone interview on 11/30/23 at 10:10 A.M. with Nurse #6, they said the following: Nurse #5 and Nurse #6 said they were aware of Resident #2's inappropriate sexual behaviors while he/she resided on the first floor Unit. Nurse #5 said that Resident #2 would make inappropriate sexual comments regarding what he/she would like to do to other residents if he/she was alone with them. Nurse #6 said that she was aware that Resident #2 had looked down CNA #7's shirt during a shower. Nurse #6 said that Resident #2 told her that he/she would take his/her medications if she (Nurse #6) made out with him/her. Nurse #6 said that CNAs told her that Resident #2 asked them (CNAs) to wash his/her genital area, despite being capable of washing him/herself. During an interview on 11/24/23 at 11:55 A.M., CNA #4 said that she worked with Resident #2 after his/her transfer to the second-floor dementia Unit (transferred on 11/13/23). CNA #4 said that on one occasion (exact date unknown sometime between 11/13/23 and 11/18/23) when she provided care for Resident #2, Resident #2 said to her, wash my genitals harder. CNA #4 said that on another occasion (exact date unknown, sometime between 11/13/23 to 11/18/23) when she asked Resident #2 whether he/she was ready to get into bed, Resident #2 replied, are you coming to bed with me? CNA #4 said that she did not document or report Resident #2's sexually inappropriate behaviors toward her because when she redirected him/her, he/she apologized. The Psychiatric Nurse Practitioner said that Facility staff members did not tell her about Resident #2's sexually inappropriate behaviors with residents and staff. The Psychiatric Nurse Practitioner said that it was important for her to know about these types of incidents so that she could assess the risk Resident #2 posed to him/herself and others, and so she could follow-up for medication changes or the need for hospitalization . CNA #1 said on 11/19/23, the next time she walked past the dining room area, she saw that Resident #1 and Resident #2 were no longer seated there and said she assumed they had gone to activities. CNA #1 said Resident #1's walker was still next to the chair where he/she had been seated and said she assumed Resident #1 had left the walker behind. CNA #1 said that a short time later (sometime between 1:30 P.M. and 2:00 P.M.) she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #1's genital area. CNA #1 said Resident #1's body was completely lifeless and he/she was looking toward the window with a facial expression that looked as though his/her soul had left his/her body. CNA #1 said that she screamed out, Resident #2 is having sex with Resident #1, and Nurse, Nurse, Nurse, and said Resident #1 did not even flinch when she screamed. CNA #1 said Resident #2 responded to her screams by yelling, get the hell out of here, and continued to thrust his/her hips against Resident #1's genital area. CNA #1 said that other staff members came to Resident #2's room in response to her screams. During in-person interviews on: - 11/22/23 at 9:14 A.M. with Nurse #1, - 11/24/23 at 11:20 A.M. with Nurse #2 , - 11/22/23 at 9:36 A.M. with Nurse #3, - 11/24/23 at 11:25 A.M. with CNA #2, - 11/24/23 at 12:47 P.M. with CNA #3, and, - 11/22/23 at 12:30 P.M with CNA #5, all said they went to Resident #2's room in response to CNA #1's screams. Nurse #2, CNA #3, and CNA #5 said they saw Resident #2 on top of Resident #1 in Resident #2's roommate's bed. Nurse #2 said Resident #2 was humping Resident #1. Nurse #1, Nurse #3 and CNA #2 said by the time they arrived to Resident #2's room, Resident #2 had been removed off of Resident #1 by staff and he/she was standing next to the bed. Nurse #1, Nurse #2, Nurse #3, CNA #1, CNA #2 and CNA #3 all said that Resident #2 was naked from the waist down and Resident #1 was completely naked, lying on his/her back in the bed. CNA #2 and CNA #3 said Resident #2 was angry and wanted staff members to get out of the room. Nurse #1, Nurse #3, CNA #1, and CNA #3 said that while exiting the room, Resident #2 stated, can we not make a big deal out of this, let's forget this, and, can we keep this between us. Nurse #2 said that he had the impression that Resident #2 felt caught. Nurse #2 said Resident #2 became agitated as staff members removed him/her from the room but said he did not know exactly what Resident #2 said. Nurse #2 and Nurse #3 said they checked Resident #1 after Resident #2 was escorted from the room by staff members. Nurse #2 said Resident #1 was distraught, shaking and weeping. Nurse #3 said that Resident #1's face looked drained, shocked and he/she was shaking. Nurse #2 and Nurse #3 said that there was a scant amount of blood on Resident #1's genital area. Nurse #2 said there was a wet area on the sheet beneath Resident #1 which he thought was urine. Nurse #3 said that there was blood on the sheet as well. Nurse #2 said he knew Resident #1 well and that his/her mental status was impaired. Nurse #2 said that he thought that if Resident #1 got his/herself into a sexual situation with Resident #2, he/she would not have had the mental capacity to get him/herself out of the situation if he/she wanted to. Nurse #3 said that she found Resident #1's clothes on Resident #2's bed. Nurses #2 and Nurse #3 said they dressed Resident #1 and then the CNAs assisted him/her back to his/her room. Nurse #3 said that when the CNAs attempted to ambulate Resident #1 back to his/her room, he/she was limping and shaking. CNA #1 and CNA #2 said someone brought Resident #1's walker to Resident #2's room and, when they tried to assist Resident #1 to ambulate to his/her room, his/her knees buckled, and he/she could not walk. CNAs #1 and #2 said they used a wheelchair to bring Resident #1 to his/her room. CNA #1, CNA #2 and CNA #3 said that once they were in Resident #1's room, Resident #1 cried. The CNAs said that when CNA #1 asked Resident #1 whether he/she was in pain and Resident #1 said he/she was, and when asked where the pain was, that Resident #1 pointed between his/her legs. Nurse #2 and CNA #5 said that Resident #1 could not have undressed him/herself without assistance. During interviews on 11/24/23 at 11:55 A.M. with CNA #4 and on 11/24/23 at 12:38 P.M. with CNA #9, they said that Resident #1 could not have undressed him/herself without assistance. The Facility Report regarding the investigation of the incident indicated that Resident #1 had a small abrased area on his/her forehead and he/she had leg discomfort. The Emergency Medical Service (EMS) Report, dated 11/19/23, from the ambulance service that transported Resident #1 to the Hospital Emergency Department that day, indicated that Resident #1 had multiple abrasions on his/her face which, according to facility staff members, were new injuries. The Hospital Emergency Department (ED) Report, dated 11/19/23, indicated Resident #1 was examined and a superficial abrasion/laceration was observed on the left side of his/her genital area, as well as scant discharge. The ED Report indicated Resident #1 had a small abrasion in the center of his/her forehead and there was a concern for a minor head injury. The ED Report indicated Resident #1 had an x-ray of his/her right knee which revealed no fracture and a computed tomography (CT) scan of his/her head which indicated no acute traumatic intracranial process. The ED Report indicated Resident #1 has an examination by the sexual assault nurse examiner which included a forensic physical examination and evidence collection, documentation of assault and physical findings, medication management, crisis intervention, discharge planning and referrals. During an interview on 11/22/23 at 3:39 P.M., the Director of Nursing (DON) said that she was not aware that Resident #2's Referral Paperwork indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The DON said that a resident with that history warranted a second level clinical review by the Facility before an offer to admit was made. The DON said she was not aware that Resident #2 had exhibited inappropriate sexually behaviors with staff or other residents, while he/she resided at the facility. During an interview on 11/24/23 at 10:30 A.M., the Director of Nurses and the Administrator said that Resident #1 and Resident #2 were not able to consent to sexual activity. Although Resident #1's impaired cognitive status limited his/her recollection of the resident to resident sexual assault by Resident #2, and lacked the ability to consent to sexual activity, an unimpaired individual would experience physical pain and mental anguish when a confused, naked person got on top of them and thrusted their genital area against them with sufficient force to cause a laceration and bleeding to his/her genital area.

Based on records review and interviews for one of three sampled residents (Resident #2) who had been recently admitted to the facility in October of 2023, and whose admission referral paperwork provided to the facility included an allegation that he/she had choked his/her significant other, and who since his/her admission had made sexually inappropriate comments to female staff members, had grabbed a female staff members' top in an attempt to look at her breasts while she was giving him/her a shower, and on at least once occasion approached another residents' room and asked that resident if he/she was just going to stand there or get into bed with him/her, the facility failed to ensure they developed and implemented a comprehensive care plan that specifically addressed Resident #2's sexually inappropriate behaviors that included interventions, measurable goals and outcomes. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of Resident #1 who had no clothes on. Resident #1 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. Resident #1 was assessed and complained of genital/pelvic area pain, with blood and discharge also observed in that same area. Resident #1 was transferred to the Hospital Emergency Department for evaluation, where he/she also complained of head, leg and knee pain. Resident #1 also underwent a Sexual Assault Nurse Exam (SANE) (forensic nursing care to victims of sexual assault which included a forensic physical examination and evidence collection, documentation of the assault and physical findings, medication management, crisis intervention, discharge planning and referrals). Resident #1 needed to be sedated in the ED, and has experienced night terror since the sexual assault. Findings include: The Facility Care Planning Policy, most recently updated 10/22/22, indicated that the Facility would develop and implement a person centered care plan for each resident which included measurable objectives and timeframe's to meet the resident's medical, nursing and mental and psychosocial needs. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident to resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of the Police Report, dated 11/19/23 indicated that police officers were dispatched to the Facility at 1:50 P.M. after a sexual offense occurred on the Alzheimer's/Dementia Unit. Review of Resident #2's pre-admission Referral Paperwork, provided by the Admission Director, which documented information from the hospital stay that preceded Resident #2's Facility Admission, indicated that Resident #2 had a history of violence toward others and per reports, attempted to choke his/her significant other. During an interview on 11/22/23 at 10:00 A.M., the Admission Director said that she had not read (missed it when she read the referral) the information on Resident #2's Referral Paperwork which indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The Admission Director said that although the screening liaison could have offered a bed at the Facility for Resident #2 with his/her history, said she should have seen the information on the referral and made sure the interdisciplinary team was aware of his/her history. Review of Resident #2's Admission MDS, dated [DATE], indicated that he/she had been admitted to the Facility during October 2023, his/her cognitive patterns were severely impaired, he/she wandered daily, and his/her health care proxy had been activated. The MDS indicated Resident #2 was 5'2 tall and weighed 178 pounds. Review of Resident #2's Care Plan for Behaviors, effective 10/18/23, indicated that he/she was at risk for behaviors including exit seeking and aggression toward staff members with verbal yelling and swearing, inappropriate racial comments to people of color and becoming animated while talking about hockey and displaying types of hits. The goal for Resident #2's Care Plan was that he/she would display fewer episodes of agitated behavior. The Care Plan interventions, which were all initiated 10/18/23, included assessing for triggers, providing a structured routine, encouraging family visits, providing safety while enabling free movement around the facility, medicating as ordered and notifying the physician or nurse practitioner of medication, behavior or safety issues. Review of the Care Plan indicated there was no documentation to support the Facility having developed and implemented a person-centered care plan for Resident #2 which included measurable objectives and timeframe's to meet Resident #2's needs as related to his/her history of violence toward others, including an attempt to choke his/her companion. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #2's past medical history included adjustment disorder with mixed disturbance of emotions and conduct, dementia, anxiety and delusional disorder. The Report indicated Resident #2 had a history of exit seeking, agitation, pacing, verbal aggression/yelling and he/she often got out of bed at night and wandered. The Report indicated Resident #2 was a limited historian and confused at baseline. The Report indicated Resident #2 had a significant history of trauma, a history of unsafe behaviors/agitation/verbal aggression. During an interview on 11/22/23 at 11:55 A.M., Certified Nurse Aide (CNA) #7 said that she provided one or two showers to Resident #2 while he/she was on the first-floor unit (the Unit where Resident #2 resided between 10/18/23 and 11/13/23). CNA #7 said that during one shower, Resident #2 pulled her shirt collar away from her chest and looked down her shirt. CNA #7 said that when she told Resident #2 that he/she could not do that, Resident #2 said to her, you can have me here naked, and I can't take a peek at your boobs? During an interview on 11/22/23 at 10:30 A.M., CNA #1 said that Resident #3 told her that Resident #2 had come to his/her room and asked about getting him/her to get into bed together. CNA #1 said that Resident #3 told her that he/she was afraid of Resident #2. During an interview on 11/22/23 at 11:40 A.M., Resident #3 (who resided on the first floor Unit) said that Resident #2 (exact date unknown, but was sometime during 10/18/23 and 11/13/23 when Resident #2 had resided on the first floor unit) came into his/her room and said to him/her, are you going to stand there or are you going to come to bed with me. Resident #3 said that Resident #2 said they could get into either one of their beds. Resident #3 said that he/she told Resident #2 no and to leave his/her room or he/she would call the police and said that Resident #2 got mad at him/her. Resident #3 said that she reported the incident to staff members. Resident #3 said that after the incident, he/she felt afraid that Resident #2 would try to crawl into his/her bed while he/she was sleeping. During a telephone interview on 11/30/23 at 9:45 A.M. with Nurse #5 and a telephone interview on 11/30/23 at 10:10 A.M. with Nurse #6, they said the following: Nurse #5 and Nurse #6 said they were aware of Resident #2's inappropriate behavior on the first-floor Unit. Nurse #5 said that Resident #2 would make inappropriate sexual comments regarding what he/she would like to do to other residents if he/she was alone with them. Nurse #6 said that she was aware that Resident #2 had looked down CNA #7's shirt during a shower. Nurse #6 said that Resident #2 told her that he/she would take his/her medications if she (Nurse #6) made out with him/her. Nurse #6 said that CNAs told her that Resident #2 asked them (CNAs) to wash his/her genital area, despite being capable of washing him/herself. Further review of Resident #2's Care Plan for Behaviors, indicated that, despite nursing staff being aware of his/her sexually inappropriate behaviors directed at staff, sexually inappropriate comments made to staff expressing what he/she would like to do to other residents, and on one occasion where he/she approached, was inappropriate and frightened another resident, there was no documentation to support that the Care Plan was, reviewed, revised or updated to include and address the sexual behaviors, with new interventions, goals and outcomes. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #2 twice during his/her stay at the Facility, and said Resident #2 was confused, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #2 had a significant trauma history and was very focused on a previous female companion during her initial assessment meeting with him/her. The Psychiatric Nurse Practitioner said Resident #2's judgement and decision-making were impaired and he/she could not consent to sexual activity. Review of the Interdisciplinary Progress Note, dated 11/10/23, indicated Resident #2 made threats to harm him/herself and staff and was sent to the hospital for evaluation. During an interview on 11/22/23 at 2:20 P.M., Social Worker #1 said that on 11/10/23 Resident #2 wanted to leave the Facility and had stated, he/she might as well kill him/herself and if he/she had a gun he/she would blow his/her brains out. Review of the Hospital Discharge Summary, dated 11/10/23, indicated Resident #2 was seen in the emergency department for dementia and agitation. The Summary indicated Resident #2 required sedation in the emergency department with anti-psychotic and antianxiety medication due to very aggressive behaviors with staff members in the emergency department. Further review of Resident #2's Care Plan for Behaviors indicated there was no documentation to support the Facility reviewed, revised or updated the Care Plan after he/she returned to the facility after his/her need for psychiatric evaluation in the emergency department after he/she had made threats to harm him/herself or to address the reports of aggressive behaviors he/she exhibited while in the ED. Further review of Resident #2's Medical Record indicated there was no documentation to support the facility either reviewed, revised and updated his/her existing Care Plan for Behaviors or developed and implemented a person-centered care plan for Resident #2 which included measurable objectives and timeframe's specifically to meet Resident #2's needs related to his/her history of sexually inappropriate behaviors toward staff members and his/her sexualized comments to and about residents, prior to his/her transfer to the second floor Dementia Unit on 11/13/23. During an interview on 11/22/23 at 1:53 P.M., Unit Manager #1 said that she was the unit manager on the first-floor Unit where Resident #2 resided from 10/18/23 to 11/13/23. Unit Manager #1 said that Resident #2 was moved to the second floor Unit on 11/13/23 following the incident in which he/she was sent to the emergency department on 11/10/23. Unit Manager #1 said that the primary reason for Resident #2's transfer was because he/she was at risk for elopement and he/she had been noted to be going to the facility lobby unescorted since he/she had been evaluated at the emergency department on 11/10/23. Unit Manager #1 said that at the time of Resident #2's transfer to the second floor Unit, she was not aware of Resident #2's sexually inappropriate behaviors including the incidents in which he/she looked down CNA #7's shirt and asked Resident #3 when they were going to go to bed together. The Psychiatric Nurse Practitioner said that Facility staff members did not tell her about Resident #2's sexually inappropriate behavior with residents and staff. The Psychiatric Nurse Practitioner said that it was important for her to know about these types of incidents so that she could assess the risk Resident #2 posed to him/herself and others and she could follow-up for medication changes or the need for hospitalization . Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors, he/she required extensive assistance with dressing and his/her health care proxy had been activated. The MDS indicated Resident #1 was 5'3 tall and weighed 147 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #1's review of systems indicated he/she experienced anxiety, dementia and depression and he/she was a limited historian and confused at baseline. The Report indicated Resident #1 was easy to engage and when asked how he/she was feeling stated, Oh, I am so happy, I love you. The Report indicated the plan was to continue to monitor Resident #1's mood, behavior and safety. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #1 several times during his/her stay at the Facility and Resident #1 was pleasant, social, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #1's judgement and decision-making were impaired and he/she could not consent to sexual activity. During an interview on 11/24/23 at 11:55 A.M., CNA #4 said that she worked with Resident #2 after his/her transfer to the second-floor Unit (transferred to second-floor dementia unit on 11/13/23). CNA #4 said that on one occasion (exact date unknown, sometime between 11/13/23 and 11/18/23) when she provided care to Resident #2, he/she stated, wash my genitals harder. CNA #4 said that on another occasion (exact date unknown, sometime between 11/13/23 and 11/18/23), when she asked Resident #2 whether he/she was ready to get into bed, Resident #2 replied, are you coming to bed with me. CNA #4 said that she did not document or report Resident #2's sexually inappropriate comments and behavior toward her because when she redirected him/her, he/she apologized. Review of Resident #2's Care Plans indicated there was no documentation to support the Facility either developed and implemented a person-centered care plan or reviewed, revised and updated his/her existing care plan for behaviors which included measurable objectives and timeframe's that specifically meet Resident #2's needs as related to sexually inappropriate behaviors toward staff members, after he/she transferred to the second-floor dementia Unit. During an interview on 11/22/23 at 10:30 A.M. CNA #1 said that she witnessed what she believed was Resident #2 trying to have sex with Resident #1 on 11/19/23. CNA #1 said on 11/19/23 sometime around 1:30 P.M. to 2:00 P.M., she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #1's genital area. CNA #1 said that she screamed for help from other staff on the unit. CNA #1 said Resident #2 responded to her screams by yelling, get the hell out of here, and continued to thrust his/her hips against Resident #1's genital area. During a telephone interview on 12/03/23 at 10:20 A.M., Family Member #1 said that on 11/19/23, a Facility staff member (exact name unknown) called her and reported that Resident #1 and Resident #2 had been found having sexual intercourse. Family Member #1 said the staff member told her Resident #1 was totally naked in Resident #2's room. Family Member #1 said the staff member told her that Resident #2 had also been naked and had been on top of Resident #1 thrusting his/her genital area against Resident #1's genital area. Family Member #1 said that Facility staff members told her that Resident #2 was a new resident and that they did not really know what his/her behaviors were. Family Member #1 said that when she arrived at the Hospital where Resident #1 had been transferred, Resident #1 was with the police, a sexual assault advocacy social worker and the hospital social worker. Family Member #1 said that Resident #1 was flipping out, crying and raging. Family Member #1 said that Resident #1 complained of pain in his/her body from Resident #2's weight being on top of him/her. Family Member #1 said that hospital staff were trying to comfort Resident #1, and that Resident #1 had to be sedated in the ED. Family Member #1 said since the sexual assault, Resident #1 has experienced night terrors during which he/she stood up to get away and has fallen. Family Member #1 also said that since the sexual assault Resident #1 has been resisting care, swearing at staff members and being difficult, which were behaviors he/she had not exhibited prior to the sexual assault. The Hospital Emergency Department (ED) Report, dated 11/19/23, indicated Resident #1 was examined and a superficial abrasion/laceration was observed on the left side of his/her genital area, as well as scant discharge. The ED Report indicated Resident #1 had a small abrasion in the center of his/her forehead and there was a concern for a minor head injury. The ED Report indicated Resident #1 had an x-ray of his/her right knee which revealed no fracture and a computed tomography (CT) scan of his/her head which indicated no acute traumatic intracranial process. The ED Report indicated Resident #1 has an examination by the sexual assault nurse examiner. During an interview on 11/22/23 at 7:15 A.M., the Director of Nurses said that prior to 11/19/23, she was not aware that Resident #2 exhibited sexually inappropriate behaviors toward staff or residents. During a follow-up interview in 11/22/23 at 3:39 P.M., the Director of Nursing (DON) said that she was not aware that Resident #2's pre-admission Referral Paperwork indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The DON said that a resident with that type of history warranted a second level clinical review by the Facility before an offer to admit was made. The Director of Nursing said that following incidents in which residents exhibited sexually inappropriate behaviors, staff members should report the incidents and the Facility should investigate the incidents and develop a care plan.

Based on interviews and records reviewed for one of three sampled residents (Resident #1) the Facility failed to ensure they obtained and maintained evidence that their investigation was conducted in a manner consistent with Federal Regulations and Facility Policy, which included ensuring their investigation was thorough, when on 11/19/23 nursing staff failed to conduct and document their physical examination of Resident #1 following a resident to resident incident of sexual abuse. Findings include: Review of the Resident Abuse Prevention,, Investigation and Reporting Policy, most recently reviewed 2/27/17, indicated that the Administrator or designee, shall as promptly as possible after report of an incident, examine and speak to the resident. Review of the Accidents and Incidents-Investigation and Reporting Policy, most recently reviewed 12/29/11, indicated that: - all accidents or incidents involving residents occurring on the premises must be investigated, - an Incident Report must be completed for all reported accidents and incidents, and, - the licensed nurse shall examine all accident/incident victims. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident-to-resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of Resident #1's most recent Quarterly Minimum Data Set Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors and his/her health care proxy had been activated. During an interview on 11/22/23 at 10:30 A.M. Certified Nurse Aide (CNA) #1 said that on 11/19/23 around 1:30 P.M., she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #2's genital area. CNA #1 said it looked like Resident #2 was having sex with Resident #1. CNA #1 said that she screamed and other staff members responded to Resident #2's room. During interviews on 11/24/23 at 11:20 A.M. with Nurse #2 and on 11/22/23 at 9:36 A.M. with Nurse #3, they said the following: Nurse #2 and Nurse #3 said that, after the incident, they checked Resident #1 while he/she was in Resident #2's roommate's bed and dressed him/her. Nurses #2 and Nurse #3 said that they observed a scant amount of blood on Resident #1's genital area. Nurse #3 said that she saw blood on the sheet beneath Resident #1 and Nurse #2 said that he saw a wet spot on the sheet beneath Resident #1 which he thought was urine. Review of the Facility Internal Investigation Report, dated 11/19/23 indicated that although there was documentation that Resident #1 was found with a scant amount blood on his/her genital area, there was no documentation to support that nursing staff had completely assessed Resident #1 for potential injury, following an alleged incident of resident to resident sexual abuse with Resident #2, including the condition of his/her skin. Review of Resident #1's Interdisciplinary Progress Note, dated 11/19/23 and written by Nurse #1, indicated that Resident #1 was brought to his/her room for a skin check and his/her skin was intact. During an interview on 11/22/23 at 9:14 A.M., Nurse #1 said that she saw Resident #1 in his/her room following the incident of resident to resident abuse with Resident #2. Nurse #1 said that she did not examine Resident #1 and said she thought that Nurse #2 and Nurse #3 had examined Resident #1 before they dressed him/her. The Facility report regarding the investigation of the incident of resident to resident sexual abuse between Resident #1 and Resident #2 indicated that Resident #1 had a small abrased area on his/her forehead and leg discomfort. The Emergency Medical Service (EMS) Report, dated 11/19/23, from the ambulance service that transported Resident #1 from the Facility to the hospital, indicated that Resident #1 had multiple abrasions on his/her face which according to facility staff members, were new injuries. The Hospital Emergency Department (ED) Report, dated 11/19/23, indicated Resident #1 was examined and a superficial abrasion/laceration was observed on the left side of his/her genital area, as well as scant discharge. The ED Report indicated Resident #1 had a small abrasion in the center of his/her forehead and there was a concern for a minor head injury. The ED Report indicated Resident #1 had an x-ray of his/her right knee which revealed no fracture and a computed tomography (CT) scan of his/her head which indicated no acute traumatic intracranial process. The ED Report indicated Resident #1 has an examination by the sexual assault nurse examiner. During an interview on 11/28/23 at 3:00 P.M., the Surveyor asked the Director of Nursing whether there was an examination conducted by nursing of Resident #1 at the Facility before he/she was transported to the hospital, including an assessment of his/her skin, and she said that there was not. The Director of Nursing said that there was no documentation to support the Facility having completed an assessment of Resident #1's body following the incident of resident to resident abuse that had occurred between Resident #1 and Resident #2. The Director of Nursing said that when she arrived at the Facility on 11/19/23 after the incident, Resident #1 was already back in his/her bed and said she assumed that a skin check had been completed by nursing staff before Resident #1 had been dressed. The Director of Nursing said that she could not explain the reason why nursing staff had not completed an examination of Resident #1's body, including his/her skin following the resident to resident incident. The Director of Nursing said that she did not see multiple abrasions on Resident #1's face, as indicated in the EMS and ER reports, when she saw Resident #1 in his/her room following the incident on 11/19/23. The Director of Nursing said she could not provide documentation of the condition of Resident #1's face/body after the alleged incident, other than nursing staff finding of a scant amount of blood in his/her genital area.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the Facility failed to ensure nursing staff members provided care and services that met professional standards of practice, when on 11/19/23, after an alleged incident of resident-to-resident sexual abuse (potential sexual assault) Nurse #1 was heard, by multiple staff members making unprofessional comments regarding the incident in Resident #1's (the alleged victims) room, in his/her presence, during which she implied that Resident #1 had been flirting with Resident #2 (the alleged perpetrator) all day and needed to more careful. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that the registered nurse shall provide and coordinate health teaching required by individuals, families and groups so as to maintain the optimal possible level of health and serve as patient advocate, within the limits of the law. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility Resident Rights Policy, most recently reviewed 10/04/23, indicated that a resident has the right to a dignified existence and the Facility must treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident-to-resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of Resident #1's most recent Quarterly Minimum Data Set Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors and his/her health care proxy had been activated. During an interview on 11/22/23 at 10:30 A.M. Certified Nurse Aide (CNA) #1 said that she witnessed what she believed was Resident #2 trying to have sex with Resident #1 on 11/19/23. CNA #1 said on 11/19/23 sometime around 1:30 P.M. to 2:00 P.M., she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #2's genital area. CNA #1 said Resident #1's body was completely lifeless, he/she was looking toward the window with a facial expression that looked as though his/her soul had left his/her body. During an interview on 11/24/23 at 11:20 A.M. with Nurse #2 and on 11/22/23 at 9:36 A.M. with Nurse #3 they said they went to Resident #2's room in response to CNA #1's screams. Nurse #2 and Nurse #3 said they dressed Resident #1 following the resident to resident incident and the CNAs assisted him/her to his/her room. During interviews on 11/24/23 at 11:25 A.M. with CNA #2 and 12:47 P.M. with CNA #3, they said they, along with CNA #1 assisted Resident #1 to his/her room after the resident to resident incident with Resident #2. CNA #1, CNA #2 and CNA #3 said that once they were in Resident #1's room, Resident #1 started to cry and complained of pain. CNA #1, CNA #2 and CNA #3 said that at one point, Nurse #1 came to Resident #1's room and stated directly to Resident #1, you have to be more careful! CNA #1, CNA #2 and CNA #3 said they could not believe what Nurse #1 said, and just looked at her but did not respond to her statement. CNA #1, CNA #2 and CNA #3, said that Nurse #1, who was still standing in front of Resident #1, then said he/she has been flirting with Resident #2 all day. During an interview on 11/22/23 at 9:14 A.M., Nurse #1 said that she thought she said we need to be careful with Resident #1, referring to the staff members and not you (as in Resident #1). Nurse #1 acknowledged that she told CNA #1, CNA #2 and CNA #3 that Resident #1 had been flirting with Resident #2 all day, while Resident #1 was in earshot of her comment. During an interview on 11/24/23 at 11:00 A.M., the Director of Nursing said that on 11/19/23 when she arrived at the Facility to initiate an investigation into an incident of resident to resident abuse involving Resident #1 and Resident #2, that Nurse #1 told her that CNA #1 was upset with her. The Director of Nursing said that Nurse #1 told her that CNA #1 thought that something she said to Resident #1 was insensitive. The Surveyor asked the Director of Nursing whether Nurse #1 or CNA #1 told her that Nurse #1 stated you have to be more careful and had also implied that Resident #1 has been flirting with Resident #2 all day. The Director of Nursing said she had only heard that CNA #1 did not like what Nurse #1 said, and that she had not yet investigated it further. Although Resident #1's impaired cognitive status limited his/her ability understand Nurse #1's statements, an unimpaired individual would experience mental anguish when being blamed for flirting with the perpetrator after being the victim of resident to resident sexual abuse (potential sexual assault).

Based on interview and record review, the facility failed to conduct initial or annual comprehensive assessments through completion of Minimum Data Set (MDS) assessments for four Residents (#1, #56, #24, and #219). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for Annual Comprehensive Assessments: -The ARD (Assessment Reference Date) (item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly or SCQA (ARD of previous OBRA Quarterly assessment + 92 calendar days). -The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for Admission Comprehensive Assessments: -The ARD (item A2300) must be set no later than day 14, counting the date of admission as day 1. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period. For example, if a resident is admitted at 8:30 a.m. on Wednesday (day 1), a completed RAI is required by the end of the day Tuesday (day 14). -Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. The IDT [interdisciplinary team] may choose to start and complete the Admission comprehensive assessment at any time prior to the end of day 14. Nursing homes may find early completion of the MDS and CAA(s) beneficial to providing appropriate care, particularly for individuals with short lengths of stay when the assessment and care planning process is often accelerated. -The MDS completion date (item Z0500B) must be no later than day 14. 1. Review of the medical record for Resident #1 indicated the Annual MDS assessment had an ARD of 8/30/23. The electronic medical record indicated that as of 10/6/23 the Annual MDS had not been completed, 37 days after the ARD. 2. Review of the medical record for Resident #56 indicated the Annual MDS assessment had an ARD of 8/31/23. The electronic medical record indicated that as of 10/10/23 the Annual MDS assessment had not been completed, 43 days after the ARD. 3. Review of the medical record for Resident #24 indicated the Annual MDS assessment had an ARD of 8/30/23. The electronic medical record indicated that as of 10/6/23 the Annual MDS assessment had not been completed, 37 days after the ARD. 4. Review of the medical record for Resident #219 indicated the Admission MDS assessment had an ARD of 9/7/23. The electronic medical record indicated that as of 10/6/23 the Admission MDS assessment had not been completed, 29 days after the ARD. During an interview on 10/10/23 at 4:50 P.M., MDS Coordinator #2 said she was assisting with completing the OBRA (non-Medicare/PPS) MDS assessments for residents at the facility but was only working part-time and remotely. She said she had not been coming to the facility to complete the resident assessments. She said she was aware the MDSs were not being completed timely but she was unable to complete them all timely while working 16 hours per week. During an interview on 10/11/23 at 1:45 P.M., the Administrator said she had been notified that the MDS assessments were not being completed timely but was unaware that assessments with an ARD from August had not been completed as of this time.

Based on interview and record review, the facility failed to conduct quarterly assessments timely through completion of Minimum Data Set (MDS) assessments for seven Residents (#62, #83, #74, #6, #29, #49, and #90). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for Quarterly Assessments: The MDS completion date (item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD + 14 calendar days). 1. Review of the medical record for Resident #62 indicated the quarterly MDS assessment had an ARD of 8/31/23. The electronic medical record indicated that as of 10/6/23 the quarterly MDS had not been completed, 36 days after the ARD. 2. Review of the medical record for Resident #83 indicated the quarterly MDS assessment had an ARD of 9/1/23. The electronic medical record indicated that as of 10/10/23 the quarterly MDS had not been completed, 39 days after the ARD. 3. Review of the medical record for Resident #74 indicated the quarterly MDS assessment had an ARD of 8/22/23. The electronic medical record indicated that as of 10/10/23 the quarterly MDS had not been completed, 49 days after the ARD. 4. Review of the medical record for Resident #6 indicated the quarterly MDS assessment had an ARD of 8/9/23 and was signed as completed on 9/15/23, 37 days after the ARD. 5. Review of the medical record for Resident #29 indicated the quarterly MDS assessment had an ARD of 8/29/23 and was signed as completed on 10/4/23, 36 days after the ARD. 6. Review of the medical record for Resident #49 indicated the quarterly MDS assessment had an ARD of 8/9/23 and was signed as completed on 9/15/23, 37 days after the ARD. 7. Review of the medical record for Resident #90 indicated the quarterly MDS assessment had an ARD of 9/4/23. The electronic medical record indicated that as of 10/12/23, the quarterly MDS had not been completed, 38 days after the ARD. During an interview on 10/10/23 at 4:50 P.M., MDS Coordinator #2 said she was assisting with completing the OBRA (non-Medicare/PPS) MDS assessments for residents at the facility but was only working part-time and remotely. She said she had not been coming to the facility to complete the resident assessments. She said she was aware the MDSs were not being completed timely but she was unable to complete them all timely while working 16 hours per week. During an interview on 10/11/23 at 1:45 P.M., the Administrator said she had been notified that the MDS assessments were not being completed timely but was unaware that assessments with an ARD from August had not been completed as of this time. 48084

Based on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for four Residents (#115, #116, #24, and #103). Findings include: 1. Review of the medical record indicated Resident #115 discharged to the hospital on 8/2/23. Review of the MDS with an assessment reference date (ARD) of 8/2/23 indicated Resident #115 had a discharge status of returning to the community. During an interview on 10/12/23 at 10:45 A.M., MDS Coordinator #1 said Resident #115 discharged to the hospital and the MDS was inaccurate. 2. Review of the medical record indicated Resident #116 discharged to the community on 8/27/23. Review of the MDS with an ARD date of 8/27/23 indicated Resident #116 had a discharge status of going to an acute hospital. During an interview on 10/12/23 at 10:46 A.M., MDS Coordinator #1 said Resident #116 discharged to the community and the MDS was inaccurate. 3. Review of the 8/30/23 MDS assessment for Resident #24 indicated the Resident had adequate hearing, clear speech, was able to express ideas and wants, was able to understand others. Further review of the MDS indicated the Resident was able to participate in the Brief Interview for Mental Status (BIMS) interview with a score of 5 out of 15, had participated in the Mood interview and had participated in the Daily and Activity Preferences interview. Review of the Pain Assessment interview (Section J) indicated all responses were dashed out and a response to if the Resident could participate in the assessment (J0200) was not answered as yes or no. The MDS was signed as completed by MDS Coordinator #2. During an interview on 10/10/23 at 4:30 P.M., MDS Coordinator #1 said she had recently started working in the MDS department and started completing pain assessments with residents on 9/23/23. She said prior to that date, she was not sure how the pain interviews were being completed. During an interview on 10/10/23 at 4:50 P.M., MDS Coordinator #2 said she works part-time for the facility off-site. She said she does not come in to the facility and therefore was unable to complete any pain interviews with residents. She said if a pain assessment was not completed the section was marked with dashes to indicate it was blank. 4. Review of the most recent MDS assessment for Resident #103, dated 9/12/23, indicated the Resident had adequate hearing, clear speech, was able to express ideas and wants, and was able to understand others. Further review of the MDS indicated the Resident was cognitively intact as evidenced by a BIMS score of 13 out of 15 and had participated in the Mood interview. Review of the Pain Assessment interview (Section J) indicated all responses were dashed out and a response to if the Resident could participate in the assessment (J0200) was not answered as yes or no. The MDS was signed as completed by MDS Coordinator #2. During an interview on 10/10/23 at 4:30 P.M., MDS Coordinator #1 said she had recently started working in the MDS department and started completing pain assessments with residents on 9/23/23. She said prior to that date, she was not sure how the pain interviews were being completed. During an interview on 10/10/23 at 4:50 P.M., MDS Coordinator #2 said she works part-time for the facility off-site. She said she does not come in to the facility and therefore was unable to complete any pain interviews with residents. She said if a pain assessment was not completed the section was marked with dashes to indicate it was blank. 48084

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed and care planned to require two staff members to meet his/her care needs including being repositioned in bed, the Facility failed to ensure staff members consistently implemented interventions and provided two staff members for care that required re-positioning. - On 11/05/21, Resident #1 was found with injuries of unknown origin, including new areas of bruising to his/her left arm and left chin, and required evaluation at the Hospital Emergency Department where he/she was diagnosed with a spiral fracture to his/her left arm and a grade 4 separation (severely displaced) of the acromioclavicular joint (the collar bone, connects the arm to the body) to the same arm. Findings include: Review of Facility Policy titled, Care Planning, dated as revised 10/09/2019, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframe's to meet each resident's needs. The Policy indicates the care plan must be individualized for the resident by adding needs, interventions, and resident specific strategies based on the assessment of each discipline. Resident #1 was admitted to the Facility in January 2020, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/14/21, indicated he/she required total physical assistance of two staff members for incontinent care, transfers, and an extensive physical assist of two staff members for bed mobility. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, last updated 3/26/20, indicated he/she required extensive physical assist of two staff members for bed mobility and repositioning. Review of Resident #1's Resident Profile (communication tool) for Certified Nurse Aides (CNA's), dated 3/26/20, indicated he/she required an extensive physical assist of two staff members to perform bed mobility and repositioning. Review of Resident #1's Activities of Daily Living (ADL) Resident Flow Sheet, for October 2021 (completed by the CNA'S), indicated he/she required the physical assist of two staff members for repositioning despite location, in bed or in his/her wheelchair. Review of the report submitted by the Facility via the Health Care Facility Reporting Systems (HCFRS), dated as submitted 11/17/2021, indicated that during a family visit by Resident #1's Health Care Agent (HCA) on 11/05/21, the HCA noticed unusual bruising to Resident #1's left arm and chin. The Report also indicated Resident #1 complained of pain to the back of his/her head and was transferred on 11/05/21 to the Hospital Emergency Department for evaluation. During an interview on 11/22/21 at 3:24 P.M., the Unit Manager said that on 11/05/21, Resident # 1's HCA reported that he/she had areas of bruising to the left arm and chin. The Unit Manager said she immediately assessed Resident #1 and noted bruising to his/her left arm and chin. The Unit Manager said when she took down Resident #1's blanket to assess him/her, she also noted a lot more bruising to his/her left upper arm. The Unit Manager said Resident #1 was transferred on 11/05/21 to the Hospital Emergency Department for evaluation. During an interview on 11/22/21 at 1:08 P.M., CNA #1 said Resident #1 was on her assignment on 11/04/21 from 3:00 P.M. to 9:00 P.M., during that shift CNA #1 said she provided incontinent care and repositioned Resident #1 three times without assistance from other staff members. CNA #1 said she knew Resident #1 required physical assist of two staff members, but said she knew Resident #1 well and knew how to do it by herself. During an interview on 12/01/21 at 1:41 P.M., Nurse #1 said Resident #1 has always required extensive physical assistance of two staff members for bed mobility, incontinent care, and repositioning. During an interview on 11/22/21 at 11:55 A.M., CNA #2 said Resident #1 has always required total physical assistance of two staff members for his/her care needs. During an interview on 11/22/21 at 12:24 P.M., CNA #3 said Resident #1 is totally dependent on two staff members for all care needs. During an interview on 11/22/21 at 12:43 P.M., CNA #4 said Resident #1 required extensive to total physical assistance of two staff members for bed mobility, incontinent care, and repositioning. During an interview on 11/22/21 at 4:08 P.M., the Registered Nurse Consultant (RNC) said that the CNA's are expected to go by the Resident's Care Profile when providing care. During an interview on 12/01/21 at 2:10 P.M., CNA #6 said she works the overnight shift and has provided incontinent care in bed for Resident #1 and has turned and repositioned him/her by herself at times. During an interview on 12/07/21 at 3:02 P.M., the Director of Nurses (DON), said Resident #1 should always receive extensive to total care from two staff members. The DON said according to the Facility investigation, she knew not all CNA's were following Resident #1's plan of care. The DON said it is the expectation of the Facility that all staff members involved with any Resident follow the Plan of Care provided.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be totally dependent of two staff members with bed mobility and repositioning, the Facility failed to ensure he/she received the level of staff member assistance required to maintain safety and prevent incident or accidents resulting in an injury. - On 11/05/21 Resident #1 was found with new areas of bruising to his/her left arm and chin, Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with a spiral fracture to his/her left arm and a grade 4 separation (severely displaced) of the acromioclavicular joint (the collar bone, connects the arm to the body) to the same arm. It was later determined by the Facility that Certified Nurse Aide (CNA) #1 provided care to Resident #1 on 11/04/2021 by herself, multiple times throughout her shift, and did not ask another staff member for assistance. Findings include: Review of Facility Policy titled Resident Safety, dated 5/02/21, indicated the Facility staff will use safe practices while delivering care to each resident. Resident #1 was admitted to the Facility in January 2020, diagnosis included a [CONDITION(S)] (when blood flow to the brain stops, brain cells cannot get oxygen and they begin to die within minutes), late effects dysphagia (difficulty in swallowing) with a gastrostomy tube (surgically placed tube giving direct access to the stomach), late effects left sided [CONDITION(S)] (weakness or inability to move on one side of the body), [CONDITION(S)] (inability to fully comprehend or formulate language), dementia with behavioral issues, [CONDITION(S)], and obesity. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated , 10/14/21, indicated he/she required the total physical assistance of two staff members for incontinent care, transfers, and an extensive physical assist of two staff members for bed mobility. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, last updated 3/26/20, indicated he/she required extensive physical assist of two staff members for bed mobility and repositioning. Review of Resident #1's Resident Profile (communication tool) for Certified Nurse Aides (CNA's), dated 3/26/20, indicated he/she required extensive physical assistance of two staff members to perform bed mobility and repositioning. Review of Resident #1's Activities of Daily Living (ADL) Resident Flow Sheet, for October 2021 (completed by the CNA'S), indicated he/she required the physical assist of two staff members for repositioning despite location, in bed or in his/her wheelchair. Review of Resident #1's medical record indicated there was no documentation of a fall or any other type of incident that could explain his/her injuries. Review of the report submitted by the Facility via the Health Care Facility Reporting Systems (HCFRS), dated as submitted 11/17/2021, indicated that during a family visit by Resident #1's Health Care Agent (HCA) the HCA noticed unusual bruising to his/her left arm and chin. The Report also indicated Resident #1 complained of pain to the back of his/her head and was sent to the Hospital Emergency Department for evaluation. During an interview on 11/22/21 at 3:24 P.M., the Unit Manager said that on 11/05/21, Resident # 1's HCA reported that he/she had areas of bruising to the left arm and chin. The Unit Manager said she immediately assessed Resident #1 and noted bruising to his/her left arm and chin. The Unit Manager said when she took down Resident #1's blanket to assess him/her, she also noted a lot more bruising to his/her left upper arm. The Unit Manager said Resident #1 was transferred on 11/05/21 to the Hospital Emergency Department for evaluation. During an interview on 11/22/21 at 1:08 P.M., CNA #1 said Resident #1 was on her assignment on 11/04/21 from 3:00 P.M. to 9:00 P.M. CNA #1 said she provided incontinent care to Resident #1 three times by herself. CNA #1 said she did not get assistance from another staff member. CNA #1 said she knew Resident #1 was a two-person physical assist, but said she knew Resident #1 well and knew how to do it by herself. During an interview on 12/01/21 at 1:41 P.M., Nurse #1 said Resident #1 has always been a two staff member physical assist when he/she is in bed. During an interview on 11/22/21 at 11:55 A.M., CNA #2 said Resident #1 has always required total physical assistance of two staff members for his/her care needs. During an interview on 11/22/21 at 12:24 P.M., CNA #3 said Resident #1 is totally dependent on two staff members for all care needs. During an interview on 11/22/21 at 12:43 P.M., CNA #4 said Resident #1 required extensive to total physical assistance of two staff members for bed mobility, incontinent care, and repositioning. During an interview on 11/22/21 at 4:08 P.M., the Registered Nurse Consultant said that the CNA's are expected to go by the Resident's Care Profile when providing and meeting care needs. During an interview on 12/07/21 at 3:02 P.M., the Director of Nurses (DON), said Resident #1 should always receive extensive to total care from two staff members. The DON said it is the expectation of the Facility that all staff members involved with any Resident follow the Plan of Care when meeting the needs of each Resident. The DON said according to the Facility investigation, she knew that not all CNA's were following Resident #1's plan of care. The DON said the investigation concluded that CNA #1 did provide care to Resident #1 on 11/04/21 without the assistance of another staff member.

Based on interviews, record review, and policy review, the facility failed to ensure one Resident (#25), out of a total of 24 sampled residents, received the necessary respiratory care and services in accordance with professional standards. Findings include: Review of the facility's policy titled [CONDITION(S)] ([CONDITION(S)]) Care, revised [DATE], indicated, but was not limited to: -[CONDITION(S)] Care will be performed by a nurse or respiratory therapist per physician order -The purpose of [CONDITION(S)] Care is to maintain a clean [CONDITION(S)] stoma (opening), prevent skin irritation, and reduce risk of symptomatic infection -A licensed nurse or respiratory therapist will assess [CONDITION(S)] Resident and perform [CONDITION(S)] Care daily and as needed per the resident's comprehensive person centered care plan. Resident #24 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Review of the medical record indicated that Resident #24 had six hospitalization s between the months of [DATE] through [DATE] due to a colonic bowel and for respiratory distress. Review of the medical record indicated the Resident was sent to the emergency room (ER) via 911 on [DATE] at 7:30 A.M. due to a change in mental status and thick dark brown sputum from his/her [CONDITION(S)]. Review of the hospital record for the [DATE] admission indicated Resident #25 went into respiratory distress in the ER requiring CPR (cardio pulmonary resuscitation) during which a large amount of thick yellow secretions were removed from his/her [CONDITION(S)]. Resident #25 returned to the facility on [DATE] with new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Suction via [CONDITION(S)] as needed -[CONDITION(S)] care day and evening -[CONDITION(S)] care as needed -Change [CONDITION(S)] ties, corrugated tubing, suction canister NOC (night) shift every seven days Review of Nursing Progress Notes between [DATE] and [DATE] indicated Resident #25 received [CONDITION(S)] suctioning that resulted in large amounts of thick [MEDICATION(S)]. Review of the Physician's Admission History and Physical, dated [DATE], indicated Resident #25 was having increased respiratory distress and oropharyngeal secretions. The MD progress note indicated to continue inhalers and nebulizers. Review of a Nurse's Progress Note, dated [DATE], indicated Resident #25 was lethargic and difficult to arouse. Resident #25 was transferred to the hospital for evaluation. Review of hospital records, dated [DATE], indicated the emergency (ER) staff was concerned about the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation indicated the [CONDITION(S)] site appeared to not have been cared for properly. Upon arrival to the ER, Resident #25 had overlying [MEDICATION(S)] on his/her [CONDITION(S)] with irritation around the stoma site. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital Case Manager's documentation, dated [DATE], indicated the ER Staff was concerned about the Resident's condition when he/she arrived to the hospital. The ER Staff was reportedly concerned about the appearance of the Resident's [CONDITION(S)] site and the cleanliness of the inner cannula of the [CONDITION(S)]. In addition, the Velcro [CONDITION(S)] holder was noted to be brown, filthy and did not appear to have been changed in some time. The [CONDITION(S)] site also appeared raw. The Resident and his/her family refused to return to the facility for further treatment. Review of Resident #25's medical record did not indicate that he/she was evaluated by respiratory therapy (RT) services. During an interview on [DATE] at 11:45 A.M., Regional Consultant #1 and the Director of Nurses (DON) said they were unsure if RT ever assessed Resident #25 during his/her stay in the facility. Review of the medical record indicated inconsistent staffing during that time period with no documented evidence that the facility had trained competent staff completing the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's education on [CONDITION(S)] Care indicated that competencies and training were not completed until [DATE]; approximately four months after Resident #25 had been admitted to the facility. During an interview on [DATE] at 10:30 A.M., the Staff Development Coordinator (SDC) said she reviewed the policy and procedures with the nursing staff prior to the Resident being admitted but did not complete training with nursing staff to ensure that staff was competent in [CONDITION(S)] care prior to caring for the Resident. Review of the Nursing Progress Notes between [DATE] and [DATE] indicated nursing staff performed [CONDITION(S)] care on Resident #25 without any documented training or education.

Based on record review, observations, and staff interview, the facility failed to ensure services provided by the facility met professional standards of practice for three Residents (#25, #77, and #105), out of a total sample of 24 residents. Specifically, the facility failed 1. For Resident #25, to ensure that an abdominal wound incision site was monitored and assessed for staple removal; 2. For Resident #77, to ensure staff accurately documented the presence of a Wanderguard bracelet (resident egress monitoring system) in the medical record; and 3. For Resident #105, to follow their policy for Discharge, Against Medical Advice (AMA), by not notifying the physician of discharge and not having the Resident sign the AMA form. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Resident #25 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/23/21, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Review of the medical record indicated the Resident was admitted to the hospital from 9/5/21 through 9/17/21. During that hospital stay he/she underwent a subtotal colectomy (removal of the colon). Upon return to the facility on [DATE], the Resident had 22 staples to his/her abdomen that were to be removed on 9/22/21. Review of the Nurse's Re-admission Note, dated 9/17/21, did not address the abdominal incision or staples. Review of the September 2021 Treatment Administration Orders (TAR) did not indicate or include any monitoring of the abdominal incision. Review of Nursing Progress Notes, dated 9/17/21 through 9/30/21, did not indicate any monitoring or assessing of the abdominal incision or the status of the staples. Review of the September 2021 Physician's Orders did not indicate that any orders were obtained to monitor the abdominal incision or the staples. During an interview on 11/4/21 at 11:45 A.M., Regional Consultant #1 and the Director of Nurses reviewed the medical record. Consultant #1 said she could not provide documentation that the surgeon was notified of the staples remaining in for an additional eight days. Review of the medical record indicated Resident #25 was transferred to the hospital on 9/30/21. The hospital documentation, dated 10/1/21, indicated the Resident's abdominal incision staples were ingrown and difficult to remove causing the Resident discomfort. The hospital documentation also indicated there were dried feces in the incision. 2. Resident #77 was admitted to the facility in September 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment, dated 9/9/21, indicated Resident #77 had severe cognitive impairment as evidenced by a BIMS score of 0 out of 15, and utilized a Wanderguard bracelet daily. Review of the medical record indicated a Physician's Order for a Wanderguard bracelet on left wrist was to be checked for placement; replace if missing, every shift. Review of the Interdisciplinary Care Plans included, but was not limited to: Problem: Elopement-At risk for elopement; exit seeking behavior noted Interventions: Apply Wanderguard detection bracelet to right wrist, monitor placement each shift (4/21/21) On 11/4/21 at 7:39 A.M., the surveyor observed Resident #77 pacing in the Unit 2 hallway. The surveyor observed that the Resident did not have a Wanderguard bracelet in place on either of his/her wrists or ankles. During an interview on 11/4/21 at 8:55 A.M., Unit Manager #1 said nursing staff are supposed to verify placement and function of the Wanderguard and document it on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Unit Manager pulled up Resident #77's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. During an interview on 11/4/21 at 10:25 A.M., Nurse #4 said she did not check to see if Resident #77's Wanderguard was in place today, although she signed off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 10:25 A.M., Unit Manager #1 said the nurse should not have documented that the Wanderguard was in place on Resident #77's wrist when she had not verified that it was there. 3. Resident #105 was admitted to the facility in August 2021 for short term rehabilitative services, following a fall at home and sustaining a cervical fracture. Review of the facility's AMA Discharge Policy, last revised 2/2019, indicated in the event that a resident/legal representative on behalf expresses desire to leave the facility against medical advice or leave prior to planned discharge date , the staff of the facility will notify the attending physician. The procedure included if the discharge is not physician ordered, complete the Against Medical Advice form and have the resident/legal representative sign the AMA form. Review of the medical record indicated that on, 8/10/21, the Resident stated he/she was going home and called his/her spouse to pick him/her up. The record indicated the Social Worker and the Unit Manager spoke with the Resident and documented AMA papers were signed. Review of the Social Worker's note indicated the Resident demanded to leave today and she spoke with the Resident to allow her to make a referral for home service which the Social Worker did. The medical record had no AMA form signed by the Resident, but did have copies of the medication list that was given to the Resident. The record had no information of notifying the attending physician of the Resident demanding to leave the facility. During an interview on 11/3/21 at 2:57 P.M., the Director of Nurses reviewed the closed record and said no there were no AMA forms signed.

Based on record review and staff interview, the facility failed to provide treatment and services that adhere to professional standards of practice and failed to recognize and assess risk factors placing the Resident at risk for specific conditions and problems for one Resident (#25), out of a total sample of 24 residents. Specifically, for Resident #25, the facility failed to ensure that an abdominal wound incision site was monitored and assessed for staple removal. Findings include: Resident #25 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/23/21, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Review of the medical record indicated the Resident was admitted to the hospital from 9/5/21 through 9/17/21. During that hospital stay he/she underwent a subtotal colectomy (removal of the colon). Upon return to the facility on [DATE], the Resident had 22 staples to his/her abdomen that were to be removed on 9/22/21. Review of the Nurse's Re-admission Note, dated 9/17/21, did not address the abdominal incision or staples. Review of the September 2021 Treatment Administration Orders (TAR) did not indicate or include any monitoring of the abdominal incision. Review of Nursing Progress Notes, dated 9/17/21 through 9/30/21, did not indicate any monitoring or assessing of the abdominal incision or the status of the staples. Review of the September 2021 Physician's Orders did not indicate that any orders were obtained to monitor the abdominal incision or the staples. During an interview on 11/4/21 at 11:45 A.M., Regional Consultant #1 and the Director of Nurses reviewed the medical record. Consultant #1 said she could not provide documentation that the surgeon was notified of the staples remaining in for an additional eight days. Review of the medical record indicated Resident #25 was transferred to the hospital on 9/30/21. The hospital documentation, dated 10/1/21, indicated the Resident's abdominal incision staples were ingrown and difficult to remove causing the Resident discomfort. The hospital documentation also indicated there were dried feces in the incision.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from abuse when on 5/28/21 during the 3:00 P.M. to 11:00 P.M. shift, while Certified Nurse Aide (CNA) #1 was providing incontinence care to Resident #1, he/she complained to CNA #1 that she was being too rough and was hurting him/her, and CNA #1 responded with words to the effect of, well you hurt me, and do you want to lay in[OBSCENITY] Resident #1 was assessed by nursing on 5/28/21 and noted to have areas of bruising on his/her right hand and arm. Findings include: Review of the Facility Resident Abuse Prevention, Investigation and Reporting Policy, revised 2/17/17, indicated that the Facility defined abuse as willful infliction of injury, unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish by an individual, including a caregiver. The Policy indicated that the Facility considered an act willful if the individual committing the act did so deliberately whether or not the individual intended to inflict injury or harm. The Policy defined verbal abuse as oral, written or gestured language that willfully included disparaging or derogatory terms to residents or within their hearing distance. Review of Resident #1's clinical record indicated his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent Minimum Data Set assessment, dated 5/20/21, indicated that his/her cognitive patterns were moderately impaired. Review of the Facility's Internal Investigation, dated 5/28/21, indicated that on 5/28/21, Resident #2 (Resident #1's roommate) complained that on 5/27/21 during the 3:00 P.M. to 11:00 P.M. shift, he/she heard Resident #1 complain while CNA #1 provided care to him/her that CNA #1 was hurting him/her. The Investigation indicated Resident #2 said he/she heard CNA #1 responded to Resident #1 with words to the effect of, well you hurt me, and do you want to lay in[OBSCENITY] During an interview on 7/01/21 at 12:44 P.M., Resident #1 declined to speak to the Surveyor about the alleged incident. During an interview on 7/01/21 at 12:03 P.M., Unit Manager #1 said that on 5/28/21, she interviewed Resident #1 about the care CNA #1 provided to him/her on 5/27/21 during the 3:00 P.M. to 11:00 P.M. shift and that Resident #1 said that CNA #1's care was abusive. Unit Manager #1 said that on 5/28/21, she interviewed Resident #2 about the alleged incident on 5/27/21 during the 3:00 P.M. to 11:00 P.M. shift and Resident #2 told her that when CNA #1 cared for Resident #1, Resident #1 complained that CNA #1 hurt him/her. Unit Manager #1 said Resident #2 told her that Resident #1 stated words to the effect of, you're hurting me, and CNA #1 stated words to the effect of, well you hurt me, and, do you want to lay in[OBSCENITY] Review of Resident #2's most recent Minimum Data Set assessment, dated 5/19/21, indicated that his/her cognitive patterns were intact. During an interview on 7/01/21 at 12:15 P.M., Resident #2 said that on 5/27/21 while CNA #1 providing care to his/her roommate (Resident #1) behind the closed privacy curtain, he/she could hear what was going on. Resident #2 said she heard Resident #1 call out words to the effect of stop, stop it, and, you're hurting me, at least three times. Resident #2 said he/she asked Resident #1 and CNA #1 what was going on over there and CNA #1 replied with words to the effect of, Resident #1 hurt me, and, Resident #1 almost cut me with his/her fingernail. Resident #2 said that at one point when Resident #1 complained that CNA #1 was hurting him/her, CNA #1 stated words to the effect of, do you want to lay in[OBSCENITY] Review of the Facility Internal Investigation indicated that skin assessments completed on Resident #1 on 5/28/21 identified that Resident #1's right arm had discolored, reddened areas along the hand, forearm and upper arm. Review of a Nurse Progress Note, dated 5/28/21 at 15:59 described three areas of bruising on Resident #1's right upper extremity: an area which measured 0.5 centimeters (cm) by 0.5 cm on Resident #1's right upper arm; a reddened area which measured 2 cm by 2 cm on Resident #1's right elbow, and, a red and blue area which measured 2 cm by 1 cm on Resident #1's right ring finger. During an interview on 7/19/21 at 2:01 P.M., the Director of Nurses said that although she and Unit Manager #1 did not ask Resident #1 whether the bruises on his/her right arm occurred during the care by CNA #1 which he/she described as abusive, the bruises had not been identified during his/her most recent skin assessment on 5/22/21. The Director of Nurses said and review of Resident #1's Progress Notes indicated no other incidents had been documented as occurring between 5/22/21 and 5/28/21 which would explain the bruises. The Director of Nurses said that no staff recalled any other incident which could explain the bruises. During an interview on 7/21/21 at 3:08 P.M., CNA #1 said that she cared for Resident #1 on 5/27/21 during the 3:00 P.M. to 11:00 P.M. shift and Resident #1 did not complain about the care. CNA #1 said Resident #2 was rude to her while she cared for Resident #1. CNA #1 said she did not see any bruises on Resident #1 on 5/27/21. CNA #1 said she could not explain Resident #2's statement that Resident #1 complained that CNA #1 hurt him/her or that CNA #1 asked Resident #1 whether he/she wanted to lie in[OBSCENITY] On 7/01/21, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) Resident #1's care plan was updated on 5/28/21 to include monitoring of bruises on Resident #1's arm until resolved. B) The Social Work Assistant said that on 5/28/21, she initiated a daily check in with Resident #1 and Resident #2 to offer support and reassurance and to monitor for changes resulting from the alleged incident. C) The Director of Nurses said that on 5/28/21, she notified the Agency that employed CNA #1 of the allegation and asked the Agency to stop scheduling CNA #1 for shifts at the Facility. D) On 5/28/21, all Facility residents who could participate in an interview were interviewed by Unit Manager #1 or the Social Work Assistant regarding any concerns with care, any issues with staff and feelings of safety with appropriate follow up as needed. E) The Staff Development Coordinator provided training for all Facility staff between 5/28/21 and 5/31/21 on the Facility Abuse PowerPoint Outline of Information and the Facility Grievance procedure. F) The Facility tested all staff between 6/1/21 and 6/4/21 on their understanding of the training conducted by the Staff Development Coordinator on the Facility Abuse PowerPoint Outline of Information and the Facility Grievance procedure. G) The Director of Nurses, Unit Manager #1 and the Social Work Assistant said that since 5/28/21, Facility leadership staff make daily rounds on the Facility units to monitor for and respond to incidents impacting resident's feelings of safety and security. H) The Facility Administrator is responsible for overall compliance.

Based on record review, staff interview and observations, the facility failed for one sampled Resident #32, to prevent the development of pressure injuries and once identified, failed to follow interventions designed to heal the areas. The total sample was 27 residents. Findings include For Resident #32, the facility failed to prevent the development of pressure injuries, when the Resident was assessed as being at risk, by not having developed an initial plan of care for pressure injuries. The facility failed to identify risk factors, failed to follow wound consultant recommendations to off-load the heels and had not recognized the malfunction of the air mattress. The wound consultant physician documented that there is no relevant family history of immunosuppressive disorder, no history of collagen-vascular disease and no bleeding disorders. The physician documented that no medications were found to be affecting wound healing. A review of the Skin Integrity Management policy with a listed policy approval date of 12/22/16, indicated that residents do not develop pressure ulcers unless the resident's clinical condition demonstrates that they are unavoidable. The policy outlines the skin integrity is identified through review of assessment information. Resident #32 was admitted [DATE]. A review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident needed only supervision for bed mobility and walking in the room and hall areas and had no functional limitation with range of motion for all extremities. The Resident was continent of bowels, occasionally incontinent for urine and had no problems with skin and no pressure areas. The MDS indicated the Resident was assessed to be at risk of developing pressure ulcers and noted needing a pressure reducing mattress and needed applications of ointment (other than to feet). The MDS assessment indicated a trigger for a plan of care for pressure areas was needed. There was no initial plan of care for the potential skin breakdown given to the surveyor for review. A review of the interdisciplinary progress notes from 11/2019 - 1/17/20 indicated the Resident ambulated in the room and other areas of the unit. On 12/8/19 the Resident had slipped from a wheelchair and staff documented no injuries. The record had no information as to why a wheelchair was being utilized for the Resident. The notes for 12/15/19 and 12/18/19 both indicate the Resident ambulated in the hall and then back to his/her room. There were no other notes of possible injury to the Resident to cause a possible skin breakdown. An Interdisciplinary team note on 12/30/19 indicated an open area on the coccyx and a heel blister. A nurse's note on 1/5/20 indicated that after developing a pressure injury, the Resident was restless in bed requiring repositioning from side to side. A nurse's note dates 1/6/20 indicated that Resident #32 had two new pressure areas on the coccyx and the left heel. A review of the plan of care, indicated that 15 days after developing these new pressure injuries a plan was developed on 1/14/20. The facility staff documented the problem of the deep tissue injuries on the coccyx and bilateral heels as due to pressure. The multiple listed interventions included the need to off-load the heels as tolerated. On 1/17/20 at 8:05 A.M., the surveyor observed the Resident in bed, with both eyes closed and he/she did not respond when their name was called. Resident #32's bilateral heels were observed on a pillow (not off-loaded) and Resident #32 was lying on his/her back. On 1/21/20 7:19 A.M., the surveyor observed the Resident was lying in bed on his/her back with both feet up on a bed pillow and the heels were not off-loaded. On 1/21/20 at 8:14 A.M., the surveyor observed that the Resident's feet were still on the pillow and Resident #32 was positioned flat in the bed. The surveyor at 9:20 A.M., checked the Resident again and Resident #32 was still flat in the bed on his/her back, with both heels on top of the pillow, not off-loaded and the air mattress was still hard and firm. Unit Manager (UM) #2 and the surveyor observed the Resident and she said those heels should be off-loaded and said there is something wrong with the air mattress. The Assistant Director of Nurses (ADON), who also oversees the wound care, was asked to view the Resident and she observed the incorrect heel positioning and the rock hard air mattress. The ADON lifted up the left heel and observed the left heel with a 5 cm. (centimeter) black area. The ADON had measured the heel wound and documented on 1/21/20 at 11:57 A.M., that the left heel was at 4.2 cm. The wound physician on 1/14/20 documented the left heel wound as smaller at 3.4 cm. A review of the wound consultant reports noted the heel wounds were to be off-loaded and the physician had to surgically debride the coccyx wound on 12/31/19, 1/7/20 and 1/14/20 to remove necrotic tissue. The wound physician documented to reposition the Resident per facility protocol. The medical record had no information as to how this ambulating Resident with no functional limitations could have developed the three pressure injuries.

Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure medications were properly labeled from the pharmacy to reflect physician's orders [REDACTED]. On 7/1/17 and 7/2/17 at 11:30 A.M. and 4:30 P.M., Nurse #3 administered Novolin N (long acting insulin) instead of the Physician ordered Novolog (short acting insulin) to Resident #1. Resident #1 received glucagon (treats low blood sugar) on the night shift (11:00 P.M., to 7:00 A.M.) on 7/2/17 and 7/3/17 and was transferred to the hospital for evaluation. Findings include: Resident #1 was admitted to the facility in August 2015, medical history included: Type 2 Diabetes, chronic kidney disease stage 3, macular degeneration and vascular dementia. The Significant Change of Status Minimum Data Sheet (MDS) Assessment Form, dated 5/20/17, indicated Resident #1 had severe cognitive impairment. Resident #1's physician's orders [REDACTED].M., 11:30 A.M., 4:30 P.M. and HS (hour of sleep) daily. The Medication Variance Report, dated 7/1/17, indicated at 11:30 A.M. and 4:30 P.M. Resident #1 received Novolin N insulin instead of Novolog insulin and had an adverse outcome/effect of [DIAGNOSES REDACTED]. The Medication Variance Report, dated 7/2/17, indicated at 11:30 A.M. and 4:30 P.M. Resident #1 received Novolin N insulin instead of Novolog insulin and had an adverse outcome/effect of [DIAGNOSES REDACTED]. The Surveyor interviewed Nurse #1 at 10:20 A.M. on 9/8/17. Nurse #1 said she went to administer Resident #1's Novolog on 7/2/17 at 8:30 P.M. and noticed that the fluid in the insulin vial was cloudy and upon further investigation she noted the plastic container had a pharmacy label stating Novolog but manufacturer's label on the insulin vial inside the plastic container stated Novolin N. Nurse #1 said the pharmacy made an error and dispensed the wrong insulin and labeled it incorrectly. The Surveyor interviewed the Director of Pharmacy at 3:40 P.M. on 9/8/17. The Director of Pharmacy said the process for dispensing insulin was to remove the insulin vial from the manufacturer's box, label a plastic container with the medication and the physician's orders [REDACTED]. The Director of Pharmacy said the pharmacy staff did not follow the proper process per policy and there was a breakdown in technique which led to the mislabeling of the insulin. The Surveyor interviewed Nurse #3 at 11:03 A.M. on 9/11/17. Nurse #3 said Resident #1's insulin vial was inside a plastic container with a pharmacy label that read Novolog with Resident #1's name. Nurse #3 said she removed the insulin vial from the plastic container, drew up the appropriate amount of insulin to be administered and administered the insulin to Resident #1. Nurse #3 said she did not read what was labeled on the insulin vial inside the plastic container and dispensed the insulin from what the pharmacy label on the plastic container stated. Nurse #3 said she did not notice if the contents of the insulin vial were cloudy (indicating long acting insulin). Nurse #3 said she should have been more vigilant to observe the insulin vial carefully to notice if the fluid in the insulin vial was clear (indicating fast acting insulin) or cloudy (indicating long acting insulin). The Surveyor interviewed the Director of Nurses at 4:00 P.M. on 9/8/17. The Director of Nurses said the Pharmacy dispensed Novolin N insulin instead of Novolog insulin and the pharmacy label on the plastic container indicated Novolog insulin,but the insulin vial itself was labeled by the manufacturer as Novolin N. The Director of Nurses said the Pharmacy had mislabeled Resident #1's insulin and she notified the Pharmacy of the error.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received [MEDICATION NAME]as ordered by the Physician. On 7/1/17 and 7/2/17 at 11:30 A.M. and 4:30 P.M., Nurse #3 administered [MEDICATION NAME] N (long acting insulin) instead of the Physician ordered [MEDICATION NAME] (short acting insulin) to Resident #1. Resident #1 required emergency intervention requiring administration of [MEDICATION NAME] (treats low blood sugar) at 2:00 A.M. on 7/2/17 and 2:05 A.M. on 7/3/17 at the Facility and required transfer to the Emergency Department for evaluation and treatment for [REDACTED]. Findings include: The Nursing 2016 Drug Handbook Best Practices and Prevention of Drug Errors, indicated that unusual appearance of a solution may indicate that the wrong drug was provided by the pharmacy,closely examine all solutions before giving them and know what their appearance should be. The Handbook further indicated that incorrect labeling can result in giving the wrong drug, never give a drug whose label is incorrect and to notify the pharmacy immediately and obtain the correctly labeled drug. The Policy titled, Medication Administration-General Guidelines, dated 06/01/10, indicated prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED]. The Policy titled, Administration Procedures for All Medications, dated 09/20/13, indicated nurses should read medication label three times: prior to removing the medication package/container from the cart/drawer; prior to removing the medication from the package/container; and as the package/container is returned to the cart/drawer and to compare the label to MAR. Resident #1's clinical record indicated he/she was admitted to the facility in August 2015 and his/her medical history included: Type 2 Diabetes, [MEDICAL CONDITION] stage 3, [MEDICATION NAME] degeneration and [MEDICAL CONDITION]. The Significant Change of Status Minimum Data Sheet (MDS) Assessment Form, dated 5/20/17, indicated Resident #1 had severe cognitive impairment. Resident #1's physician's orders [REDACTED].M., 11:30 A.M., 4:30 P.M. and HS (hour of sleep) daily. Nurse #3 said she was Resident #3's nurse during the 10:00 A.M. to 6:00 P.M. shift on 7/1/17 and 7/2/17. Nurse #3 said she administered insulin to Resident #1 at 11:30 A.M. and 4:30 P.M. The Medication Variance Report, dated 7/1/17, indicated at 11:30 A.M. and 4:30 P.M. Resident #1 received [MEDICATION NAME] N insulin instead of [MEDICATION NAME]and had an adverse outcome/effect of [DIAGNOSES REDACTED]. The Nurse Progress Note and The Medical Emergency/Code Blue Flow Sheet, dated 7/2/17, indicated at 2:00 A.M. Resident #1 was non-responsive and when his/her CBG was checked, it was 39. The Nurse Progress Note and The Medical Emergency/Code Blue Flow Sheet indicated [MEDICATION NAME] (treats low blood sugar) was administered, 911 was activated and Resident #1 was transferred to the hospital. The Hospital Emergency Department Report, dated 7/2/17, indicated Resident #1's final/primary [DIAGNOSES REDACTED]. Resident #1 returned to the Facility from the hospital on [DATE] at approximately 6:10 A.M. The Medical Emergency/Code Blue Flow Sheet, dated 7/3/17, indicated at 2:05 A.M and The. Resident #1 was found in respiratory distress, with a CBG of 30, [MEDICATION NAME] was administered, 911 was activated and he/she was transferred to the hospital for evaluation. The Surveyor interviewed Nurse #3 at 11:03 A.M. on 9/11/17. Nurse #3 said Resident #1's insulin vial was inside a plastic container with a pharmacy label that read [MEDICATION NAME] with Resident #1's name. Nurse #3 said she removed the insulin vial from the plastic container, drew up the appropriate amount of insulin to be administered and administered the insulin to Resident #1. Nurse #3 said she did not read what was labeled on the insulin vial inside the plastic container and dispensed the insulin from what the pharmacy label on the plastic container stated. Nurse #3 said she did not notice if the contents of the insulin vial were cloudy (indicating long acting insulin). Nurse #3 said she should have been more vigilant to observe the insulin vial carefully to notice if the fluid in the insulin vial was clear (indicating fast acting insulin) or cloudy (indicating long acting insulin). The Surveyor interviewed the Director of Nurses at 4:00 P.M. on 9/8/17. The Director of Nurses said it is her expectation that Nurse #3 would have paid attention to the insulin vial inside the plastic container, noticed that the fluid in the insulin vial was cloudy not clear, noticed the discrepancy between what the pharmacy label on the plastic container stated, what the pharmacy label on the insulin vial inside the plastic container stated and what the manufacturers label on the insulin vial stated.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #3 followed acceptable standards of practice for administering medications. On 7/1/17 and 7/2/17 at 11:30 A.M. and 4:30 P.M., Nurse #3 failed to carefully visually inspect Resident #1's insulin vial, which was mislabeled by the pharmacy and administered [MEDICATION NAME] N (long acting insulin) instead of the Physician ordered [MEDICATION NAME] (short acting insulin) to Resident #1. Resident #1 required [MEDICATION NAME] (treats low blood sugar) twice on the night shift (11:00 P.M., to 7:00 A.M.) on 7/2/17 at 2:00 A.M. and 2:20 A.M. for a Capillary Blood Glucose (CBG) of 39. Normal Blood Glucose Range 70-100 mg/dL(milligrams per deciliter) and was transferred to the hospital for evaluation. Resident #1 required [MEDICATION NAME] again on the night shift (11:00 P.M. to 7:00 A.M.) on 7/3/17 at 2:05 A.M. for a CBG blood sugar of 30 and was again transferred to the hospital for evaluation and was admitted . Findings include: The Nursing 2016 Drug Handbook Best Practices and Prevention of Drug Errors, indicated that unusual appearance of a solution may indicate that the wrong drug was provided by the pharmacy,closely examine all solutions before giving them and know what their appearance should be. The Handbook further indicated that incorrect labeling can result in giving the wrong drug, never give a drug whose label is incorrect and to notify the pharmacy immediately and obtain the correctly labeled drug. The Policy titled, Medication Administration-General Guidelines, dated 06/01/10, indicated prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED]. The Policy titled, Administration Procedures for All Medications, dated 09/20/13, indicated nurses should read medication label three times: prior to removing the medication package/container from the cart/drawer; prior to removing the medication from the package/container; and as the package/container is returned to the cart/drawer and to compare the label to MAR. Resident #1's clinical record indicated he/she was admitted to the facility in August 2015 and his/her medical history included: Type 2 Diabetes, [MEDICAL CONDITION] stage 3, [MEDICATION NAME] degeneration and [MEDICAL CONDITION]. The Significant Change of Status Minimum Data Sheet (MDS) Assessment Form, dated 5/20/17, indicated Resident #1 had severe cognitive impairment. Resident #1's physician's orders [REDACTED].M., 11:30 A.M., 4:30 P.M. and HS (hour of sleep) daily. Nurse #3 said she was Resident #3's nurse during the 10:00 A.M. to 6:00 P.M. shift on 7/1/17 and 7/2/17. Nurse #3 said she administered insulin to Resident #1 at 11:30 A.M. and 4:30 P.M. The Medication Variance Report, dated 7/1/17, indicated at 11:30 A.M. and 4:30 P.M. Resident #1 received [MEDICATION NAME] N insulin instead of [MEDICATION NAME]and had an adverse outcome/effect of [DIAGNOSES REDACTED]. The Nurse Progress Note and The Medical Emergency/Code Blue Flow Sheet, dated 7/2/17, indicated at 2:00 A.M. Resident #1 was non-responsive and when his/her CBG was checked, it was 39. The Nurse Progress Note and The Medical Emergency/Code Blue Flow Sheet indicated [MEDICATION NAME] (treats low blood sugar) was administered, 911 was activated and Resident #1 was transferred to the hospital. The Hospital Emergency Department Report, dated 7/2/17, indicated Resident #1's final/primary [DIAGNOSES REDACTED]. Resident #1 returned to the Facility from the hospital on [DATE] at approximately 6:10 A.M. The Medical Emergency/Code Blue Flow Sheet, dated 7/3/17, indicated at 2:05 A.M and The. Resident #1 was found in respiratory distress, with a CBG of 30, [MEDICATION NAME] was administered, 911 was activated and he/she was transferred to the hospital for evaluation. The Surveyor interviewed Nurse #3 at 11:03 A.M. on 9/11/17. Nurse #3 said Resident #1's insulin vial was inside a plastic container with a pharmacy label that read [MEDICATION NAME] with Resident #1's name. Nurse #3 said she removed the insulin vial from the plastic container, drew up the appropriate amount of insulin to be administered and administered the insulin to Resident #1. Nurse #3 said she did not read what was labeled on the insulin vial inside the plastic container and dispensed the insulin from what the pharmacy label on the plastic container stated. Nurse #3 said she did not notice if the contents of the insulin vial were cloudy (indicating long acting insulin). Nurse #3 said she should have been more vigilant to observe the insulin vial carefully to notice if the fluid in the insulin vial was clear (indicating fast acting insulin) or cloudy (indicating long acting insulin). The Surveyor interviewed the Director of Nurses at 4:00 P.M. on 9/8/17. The Director of Nurses said it is her expectation that Nurse #3 would have paid attention to the insulin vial inside the plastic container, noticed that the fluid in the insulin vial was cloudy not clear, noticed the discrepancy between what the pharmacy label on the plastic container stated, what the pharmacy label on the insulin vial inside the plastic container stated and what the manufacturers label on the insulin vial stated.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), who was not initially assessed to be at risk for suicidal ideation, the Facility failed to ensure there was a system in place for communicating a change in Resident #1's psychiatric status when he/she voiced suicidal ideation and contracted for safety to his/her Licensed Mental Health Counselor. The Licensed Mental Health Counselor exited the facility without notifying the facility of a significant change in Resident #1's psychiatric status when Resident #1 voiced suicidal ideation and contracted for safety during his/her session with his/her Licensed Mental Health Counselor at 3:53 P.M. on [DATE]. Resident #1 was found with a telephone cord wrapped around her/his neck at 7:20 P.M. on [DATE], two hours after voicing suicidal ideation and contracting for safety to his/her Licensed Mental Health Counselor and was transferred to the hospital where he/she was pronounced dead. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was cognitively intact and had [DIAGNOSES REDACTED]. The Care Plan for Mood Issues, dated [DATE], indicated Resident #1 had episodes of depression and anxiety and to consult with the contracted Psychiatric Provider as needed. The Facility's Suicide Prevention Policy, dated [DATE], indicated upon resident interview, if resident indicates that life isn't worth living, the attending physician should be notified and initiate further assessment. The Policy further indicates, the resident is not to be left unattended, immediately placed on 1:1 supervision and as soon as possible, a Nurse Manager be informed of the risk. The Facility's Physician Notification Protocols, undated, indicated to immediately report to the Physician any suicidal ideation. A Patient Progress Note, dated [DATE], completed by Licensed Mental Health Counselor #1, indicated Resident #1 verbalized I don't even want to be alive, and don't know what I have to live for, was determined to be at risk for further worsening of depression and development of suicidal ideation, contracted for safety and team members can offer him/her support and inquire if she/he is having any suicidal ideation. An Incident/Accident Report, dated [DATE] at 7:20 P.M., indicated Resident #1 was found in the bathroom sitting in front of the mirror in his/her wheelchair unresponsive, with no respirations, no apical pulse and was noted to have a phone cord around his/her neck. An Situation, Background, Appearance, and Review (SBAR) Progress Note, dated [DATE], indicated Resident #1 was found in his/her bathroom sitting in wheelchair with a telephone cord wrapped tightly around his/her neck, without any pulse or respirations in a cyanotic color (blue/purple). Cardiopulmonary Resuscitation (CPR) was initiated, 911 was called and Resident #1 was transferred to the hospital. The Surveyor interviewed Licensed Mental Health Counselor #1 at 12:45 P.M. on [DATE]. Licensed Mental Health Counselor #1 said Resident #1 verbalized suicidal ideation to him during his session with him/her on [DATE]. Licensed Mental Health Counselor #1 said he did not notify the facility staff of Resident #1's verbalized suicidal ideation. Licensed Mental Health Counselor #1 said he did not identify a change in Resident #1's mental health status or believe Resident #1's care plan needed to be revised because Resident #1 verbally contracted for safety during his session with him/her. Licensed Mental Health Counselor #1 said he went back again to speak with Resident #1 between 5:00 P.M. and 6:00 P.M. on [DATE] before he exited the facility and Resident #1 once again verbally contracted for safety. Licensed Mental Health Counselor #1 said he did not inform facility staff that Resident #1 verbalized suicidal ideation. The Surveyor interviewed Unit Manager #1 at 4:45 P.M. on [DATE]. Unit Manager #1 said she thought Resident #1 was not at risk for suicidal ideation nor care planned for suicide risk. Unit Manager #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on ,[DATE], that Resident #1 made suicidal comments. Unit Manager #1 said Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's mental health status to the facility staff. Unit Manager #1 said she did not see Resident #1's psychiatric progress note, which indicated Resident #1 verbalized suicidal ideation. Unit Manager #1 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's mental health status, the physician should have been immediately notified and Resident #1 should have been placed on a 1:1. observation. Unit Manager #1 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed Unit Manager #2 at 6:00 P.M. on [DATE]. Unit Manager #2 said that prior to [DATE], Resident #1 did not verbalize suicidal ideation. Unit Manager #2 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments. Unit Manager #2 said she saw Licensed Mental Health Counselor #1 multiple times on [DATE] but Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's psychiatric status. Unit Manager #2 said she was unaware Resident #1's psychiatric progress note indicated Resident #1 was at risk for development of suicidal impulses or voiced suicidal ideation. Unit Manager #2 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's psychiatric status, the physician should have been notified and Resident #1 should have immediately been placed on a 1:1. observation. Unit Manager #2 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed the Director of Nurses at 6:10 P.M. on [DATE]. The Director of Nurses said Licensed Mental Health Counselor #1 should have immediately communicated with the facility a change in Resident #1's psychiatric status when he/she voiced suicidal ideation and needed to contract for safety during his/her session with Licensed Mental Health Counselor #1 on [DATE] as this was clearly a significant change in Resident #1's psychiatric status which needed to be immediately reported to the physician. The Director of Nurses said staff did not increase the level of supervision for Resident #1 based on the new information because they were unaware of Resident #1's change in condition. The Director of Nurses said the Licensed Mental Health Counselor communicates with the facility by leaving his progress note under the social worker's office door when he exits the facility, the next day, the social worker makes copies of the progress note and puts them in the Unit Manager and Director of Nurses' mailbox. The Surveyor interviewed Medical Examiner's Office Clerk at 11:25 A.M., on [DATE]. The Medical Examiner's Office Clerk said Resident #1's cause and manner of death is pending and can take up to 90 days to be determined.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), who was not initially assessed to be at risk for suicidal ideation, the Facility failed to ensure there was a system in place for communicating a change in Resident #1's mental status when he/she voiced suicidal ideation and contracted for safety to his/her Licensed Mental Health Counselor. The Licensed Mental Health Counselor exited the facility without notifying his supervisor of a significant change in Resident #1's psychiatric status when Resident #1 voiced suicidal ideation and contracted for safety during his/her session with his/her Licensed Mental Health Counselor at 3:53 P.M. on [DATE], which was new. Resident #1 was found with a telephone cord wrapped around her/his neck at 7:20 P.M. on [DATE], two hours after voicing suicidal ideation and contracting for safety to his/her Licensed Mental Health Counselor and was transferred to the hospital where he/she was pronounced dead. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was cognitively intact and had [DIAGNOSES REDACTED]. The Care Plan for Mood Issues, dated [DATE], indicated Resident #1 had episodes of depression and anxiety and to consult with the contracted Psychiatric Provider as needed. The Facility's Suicide Prevention Policy, dated [DATE], indicated upon resident interview, if resident indicates that life isn't worth living, the attending physician should be notified and initiate further assessment. The Policy further indicates, the resident is not to be left unattended, immediately placed on 1:1 supervision and as soon as possible, a Nurse Manager be informed of the risk. The Facility's Physician Notification Protocols, undated, indicated to immediately report to the Physician any suicidal ideation. A Patient Progress Note, dated [DATE], completed by Licensed Mental Health Counselor #1, indicated Resident #1 verbalized I don't even want to be alive, and don't know what I have to live for, was determined to be at risk for further worsening of depression and development of suicidal ideation, contracted for safety and team members can offer him/her support and inquire if she/he is having any suicidal ideation. An Incident/Accident Report, dated [DATE] at 7:20 P.M., indicated Resident #1 was found in the bathroom sitting in front of the mirror in his/her wheelchair unresponsive, with no respirations, no apical pulse and was noted to have a phone cord around his/her neck. An Situation, Background, Appearance, and Review (SBAR) Progress Note, dated [DATE], indicated Resident #1 was found in his/her bathroom sitting in wheelchair with a telephone cord wrapped tightly around his/her neck, without any pulse or respirations in a cyanotic color (blue/purple). Cardiopulmonary Resuscitation (CPR) was initiated, 911 was called and Resident #1 was transferred to the hospital. The Surveyor interviewed Licensed Mental Health Counselor #1 at 12:45 P.M. on [DATE]. Licensed Mental Health Counselor #1 said Resident #1 verbalized suicidal ideation to him during his session with him/her on [DATE]. Licensed Mental Health Counselor #1 said he did not notify the facility staff of Resident #1's verbalized suicidal ideation. Licensed Mental Health Counselor #1 said he did not identify a change in Resident #1's mental health status or believe Resident #1's care plan needed to be revised because Resident #1 verbally contracted for safety during his session with him/her. Licensed Mental Health Counselor #1 said he went back again to speak with Resident #1 between 5:00 P.M. and 6:00 P.M. on [DATE] before he exited the facility and Resident #1 once again verbally contracted for safety. Licensed Mental Health Counselor #1 said he did not inform facility staff that Resident #1 verbalized suicidal ideation. The Surveyor interviewed Unit Manager #1 at 4:45 P.M. on [DATE]. Unit Manager #1 said she thought Resident #1 was not at risk for suicidal ideation nor care planned for suicide risk. Unit Manager #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on ,[DATE], that Resident #1 made suicidal comments. Unit Manager #1 said Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's mental health status to the facility staff. Unit Manager #1 said she did not see Resident #1's psychiatric progress note, which indicated Resident #1 verbalized suicidal ideation. Unit Manager #1 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's mental health status, the physician should have been immediately notified and Resident #1 should have been placed on a 1:1. observation. Unit Manager #1 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed Unit Manager #2 at 6:00 P.M. on [DATE]. Unit Manager #2 said that prior to [DATE], Resident #1 did not verbalize suicidal ideation. Unit Manager #2 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments. Unit Manager #2 said she saw Licensed Mental Health Counselor #1 multiple times on [DATE] but Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's psychiatric status. Unit Manager #2 said she was unaware Resident #1's psychiatric progress note indicated Resident #1 was at risk for development of suicidal impulses or voiced suicidal ideation. Unit Manager #2 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's psychiatric status, the physician should have been notified and Resident #1 should have immediately been placed on a 1:1. observation. Unit Manager #2 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed the Director of Nurses at 6:10 P.M. on [DATE]. The Director of Nurses said Licensed Mental Health Counselor #1 should have immediately communicated with the facility a change in Resident #1's psychiatric status when he/she voiced suicidal ideation and needed to contract for safety during his/her session with Licensed Mental Health Counselor #1 on [DATE] as this was clearly a significant change in Resident #1's psychiatric status which needed to be immediately reported to the physician. The Director of Nurses said staff did not increase the level of supervision for Resident #1 based on the new information because they were unaware of Resident #1's change in condition. The Director of Nurses said the Licensed Mental Health Counselor communicates with the facility by leaving his progress note under the social worker's office door when he exits the facility, the next day, the social worker makes copies of the progress note and puts them in the Unit Manager and Director of Nurses' mailbox. The Surveyor interviewed Social Worker #1 at 8:40 A.M. on [DATE]. Social Worker #1 said prior to [DATE], Resident #1 was not at risk for suicidal ideation. Social Worker #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments and that Licensed Mental Health Counselor determined Resident #1 needed to contract for safety, which was new. Social Worker #1 said Licensed Mental Health Counselor #1 failed to communicate a significant change in Resident #1's psychiatric status to the facility staff. Social Worker #1 said Licensed Mental Health Counselor #1 should have communicated with the facility a change in Resident #1's psychiatric status and the physician should have been immediately notified of Resident #1's suicidal ideation. Social Worker #1 said the facility's process for communicating with Licensed Mental Health Counselor #1 was to leave the resident's progress note under the social worker's office door when he exits the facility and on the following day, the social worker makes copies of the progress note for the Unit Manager and Director of Nurses and puts the progress notes in the Unit Manager and Director of Nurses mailboxes in the conference room.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), who was not initially assessed to be at risk for suicidal ideation, the Facility failed to notify the physician when he/she voiced suicidal ideation and contracted for safety during his/her session with his/her Licensed Mental Health Counselor at 3:53 P.M. on [DATE]. Resident #1 was found with a telephone cord wrapped around her/his neck at 7:20 P.M. on [DATE], two hours after voicing suicidal ideation and contracting for safety to his/her Licensed Mental Health Counselor and was transferred to the hospital where he/she was pronounced dead. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was cognitively intact and had [DIAGNOSES REDACTED]. The Care Plan for Mood Issues, dated [DATE], indicated Resident #1 had episodes of depression and anxiety and to consult with the contracted Psychiatric Provider as needed. The Facility's Suicide Prevention Policy, dated [DATE], indicated upon resident interview, if resident indicates that life isn't worth living, the attending physician should be notified and initiate further assessment. The Policy further indicates, the resident is not to be left unattended, immediately placed on 1:1 supervision and as soon as possible, a Nurse Manager be informed of the risk. The Facility's Physician Notification Protocols, undated, indicated to immediately report to the Physician any suicidal ideation. A Patient Progress Note, dated [DATE], completed by Licensed Mental Health Counselor #1, indicated Resident #1 verbalized I don't even want to be alive, and don't know what I have to live for, was determined to be at risk for further worsening of depression and development of suicidal ideation, contracted for safety and team members can offer him/her support and inquire if she/he is having any suicidal ideation. An Incident/Accident Report, dated [DATE] at 7:20 P.M., indicated Resident #1 was found in the bathroom sitting in front of the mirror in his/her wheelchair unresponsive, with no respirations, no apical pulse and was noted to have a phone cord around his/her neck. An Situation, Background, Appearance, and Review (SBAR) Progress Note, dated [DATE], indicated Resident #1 was found in his/her bathroom sitting in wheelchair with a telephone cord wrapped tightly around his/her neck, without any pulse or respirations in a cyanotic color (blue/purple). Cardiopulmonary Resuscitation (CPR) was initiated, 911 was called and Resident #1 was transferred to the hospital. The Surveyor interviewed Licensed Mental Health Counselor #1 at 12:45 P.M. on [DATE]. Licensed Mental Health Counselor #1 said Resident #1 verbalized suicidal ideation to him during his session with him/her on [DATE]. Licensed Mental Health Counselor #1 said he did not notify the facility staff of Resident #1's verbalized suicidal ideation. Licensed Mental Health Counselor #1 said he did not identify a change in Resident #1's mental health status or believe Resident #1's care plan needed to be revised because Resident #1 verbally contracted for safety during his session with him/her. Licensed Mental Health Counselor #1 said he went back again to speak with Resident #1 between 5:00 P.M. and 6:00 P.M. on [DATE] before he exited the facility and Resident #1 once again verbally contracted for safety. Licensed Mental Health Counselor #1 said he did not inform facility staff that Resident #1 verbalized suicidal ideation. The Surveyor interviewed Unit Manager #1 at 4:45 P.M. on [DATE]. Unit Manager #1 said she thought Resident #1 was not at risk for suicidal ideation nor care planned for suicide risk. Unit Manager #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on ,[DATE], that Resident #1 made suicidal comments. Unit Manager #1 said Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's mental health status to the facility staff. Unit Manager #1 said she did not see Resident #1's psychiatric progress note, which indicated Resident #1 verbalized suicidal ideation. Unit Manager #1 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's mental health status, the physician should have been immediately notified and Resident #1 should have been placed on a 1:1. observation. Unit Manager #1 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed Unit Manager #2 at 6:00 P.M. on [DATE]. Unit Manager #2 said that prior to [DATE], Resident #1 did not verbalize suicidal ideation. Unit Manager #2 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments. Unit Manager #2 said she saw Licensed Mental Health Counselor #1 multiple times on [DATE] but Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's psychiatric status. Unit Manager #2 said she was unaware Resident #1's psychiatric progress note indicated Resident #1 was at risk for development of suicidal impulses or voiced suicidal ideation. Unit Manager #2 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's psychiatric status, the physician should have been notified and Resident #1 should have immediately been placed on a 1:1. observation. Unit Manager #2 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed the Director of Nurses at 6:10 P.M. on [DATE]. The Director of Nurses said Licensed Mental Health Counselor #1 should have immediately communicated with the facility a change in Resident #1's psychiatric status when he/she voiced suicidal ideation and needed to contract for safety during his/her session with Licensed Mental Health Counselor #1 on [DATE] as this was clearly a significant change in Resident #1's psychiatric status which needed to be immediately reported to the physician. The Director of Nurses said staff did not increase the level of supervision for Resident #1 based on the new information because they were unaware of Resident #1's change in condition. The Director of Nurses said the Licensed Mental Health Counselor communicates with the facility by leaving his progress note under the social worker's office door when he exits the facility, the next day, the social worker makes copies of the progress note and puts them in the Unit Manager and Director of Nurses' mailbox. The Surveyor interviewed Social Worker #1 at 8:40 A.M. on [DATE]. Social Worker #1 said prior to [DATE], Resident #1 was not at risk for suicidal ideation. Social Worker #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments and that Licensed Mental Health Counselor determined Resident #1 needed to contract for safety, which was new. Social Worker #1 said Licensed Mental Health Counselor #1 failed to communicate a significant change in Resident #1's psychiatric status to the facility staff. Social Worker #1 said Licensed Mental Health Counselor #1 should have communicated with the facility a change in Resident #1's psychiatric status and the physician should have been immediately notified of Resident #1's suicidal ideation. Social Worker #1 said the facility's process for communicating with Licensed Mental Health Counselor #1 was to leave the resident's progress note under the social worker's office door when he exits the facility and on the following day, the social worker makes copies of the progress note for the Unit Manager and Director of Nurses and puts the progress notes in the Unit Manager and Director of Nurses mailboxes in the conference room.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), who was not initially assessed or care planned to be at risk for suicidal ideation, the Facility failed to develop an appropriate plan of care for Resident #1 when he/she voiced suicidal ideation and contracted for safety during his/her session with his/her Licensed Mental Health Counselor at 3:53 P.M. on [DATE]. Resident #1 was found with a telephone cord wrapped tightly around her/his neck at 7:20 P.M. on [DATE] , two hours after voicing suicidal ideation and contracting for safety on two separate occasions to his/her Licensed Mental Health Counselor and was transferred to the hospital where he/she was pronounced dead. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was cognitively intact and had [DIAGNOSES REDACTED]. The Care Plan for Mood Issues, dated [DATE], indicated Resident #1 had episodes of depression and anxiety and to consult with the contracted Psychiatric Provider as needed. The Facility's Suicide Prevention Policy, dated [DATE], indicated upon resident interview, if resident indicates that life isn't worth living, the attending physician should be notified and initiate further assessment. The Policy further indicates, the resident is not to be left unattended, immediately placed on 1:1 supervision and as soon as possible, a Nurse Manager be informed of the risk. The Facility's Physician Notification Protocols, undated, indicated to immediately report to the Physician any suicidal ideation. A Patient Progress Note, dated [DATE], completed by Licensed Mental Health Counselor #1, indicated Resident #1 verbalized I don't even want to be alive, and don't know what I have to live for, was determined to be at risk for further worsening of depression and development of suicidal ideation, contracted for safety and team members can offer him/her support and inquire if she/he is having any suicidal ideation. An Incident/Accident Report, dated [DATE] at 7:20 P.M., indicated Resident #1 was found in the bathroom sitting in front of the mirror in his/her wheelchair unresponsive, with no respirations, no apical pulse and was noted to have a phone cord around his/her neck. An Situation, Background, Appearance, and Review (BAR) Progress Note, dated [DATE], indicated Resident #1 was found in his/her bathroom sitting in wheelchair with a telephone cord wrapped tightly around his/her neck, without any pulse or respirations in a cyanotic color (blue/purple). Cardiopulmonary Resuscitation (CPR) was initiated, 911 was called and Resident #1 was transferred to the hospital. The Surveyor interviewed Licensed Mental Health Counselor #1 at 12:45 P.M. on [DATE]. Licensed Mental Health Counselor #1 said Resident #1 verbalized suicidal ideation to him during his session with him/her on [DATE]. Licensed Mental Health Counselor #1 said he did not notify the facility staff of Resident #1's verbalized suicidal ideation. Licensed Mental Health Counselor #1 said he did not identify a change in Resident #1's mental health status or believe Resident #1's care plan needed to be revised because Resident #1 verbally contracted for safety during his session with him/her. Licensed Mental Health Counselor #1 said he went back again to speak with Resident #1 between 5:00 P.M. and 6:00 P.M. on [DATE] before he exited the facility and Resident #1 once again verbally contracted for safety. Licensed Mental Health Counselor #1 said he did not inform facility staff that Resident #1 verbalized suicidal ideation. The Surveyor interviewed Unit Manager #1 at 4:45 P.M. on [DATE]. Unit Manager #1 said she thought Resident #1 was not at risk for suicidal ideation nor care planned for suicide risk. Unit Manager #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on ,[DATE], that Resident #1 made suicidal comments. Unit Manager #1 said Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's mental health status to the facility staff. Unit Manager #1 said she did not see Resident #1's psychiatric progress note, which indicated Resident #1 verbalized suicidal ideation. Unit Manager #1 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's mental health status, the physician should have been immediately notified and Resident #1 should have been placed on a 1:1. observation. Unit Manager #1 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed Unit Manager #2 at 6:00 P.M. on [DATE]. Unit Manager #2 said that prior to [DATE], Resident #1 did not verbalize suicidal ideation. Unit Manager #2 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments. Unit Manager #2 said she saw Licensed Mental Health Counselor #1 multiple times on [DATE] but Licensed Mental Health Counselor #1 did not communicate a change in Resident #1's psychiatric status. Unit Manager #2 said she was unaware Resident #1's psychiatric progress note indicated Resident #1 was at risk for development of suicidal impulses or voiced suicidal ideation. Unit Manager #2 said Licensed Mental Health Counselor #1 should have communicated a change in Resident #1's psychiatric status, the physician should have been notified and Resident #1 should have immediately been placed on a 1:1. observation. Unit Manager #2 said Licensed Mental Health Counselor #1 leaves the resident's progress note in her mailbox and she reviews the progress note the next work day. The Surveyor interviewed the Director of Nurses at 6:10 P.M. on [DATE]. The Director of Nurses said Licensed Mental Health Counselor #1 should have immediately communicated with the facility a change in Resident #1's psychiatric status when he/she voiced suicidal ideation and needed to contract for safety during his/her session with Licensed Mental Health Counselor #1 on [DATE] as this was clearly a significant change in Resident #1's psychiatric status which needed to be immediately reported to the physician. The Director of Nurses said staff did not increase the level of supervision for Resident #1 based on the new information because they were unaware of Resident #1's change in condition. The Director of Nurses said the Licensed Mental Health Counselor communicates with the facility by leaving his progress note under the social worker's office door when he exits the facility, the next day, the social worker makes copies of the progress note and puts them in the Unit Manager and Director of Nurses' mailbox. The Surveyor interviewed Social Worker #1 at 8:40 A.M. on [DATE]. Social Worker #1 said prior to [DATE], Resident #1 was not at risk for suicidal ideation. Social Worker #1 said she was unaware that during Resident #1's counseling session with Licensed Mental Health Counselor #1 on [DATE], Resident #1 made suicidal comments and that Licensed Mental Health Counselor determined Resident #1 needed to contract for safety, which was new. Social Worker #1 said Licensed Mental Health Counselor #1 failed to communicate a significant change in Resident #1's psychiatric status to the facility staff. Social Worker #1 said Licensed Mental Health Counselor #1 should have communicated with the facility a change in Resident #1's psychiatric status and the physician should have been immediately notified of Resident #1's suicidal ideation. Social Worker #1 said the facility's process for communicating with Licensed Mental Health Counselor #1 was to leave the resident's progress note under the social worker's office door when he exits the facility and on the following day, the social worker makes copies of the progress note for the Unit Manager and Director of Nurses and puts the progress notes in the Unit Manager and Director of Nurses mailboxes in the conference room.

Based on record review, observation and interviews, the facility failed for 1 (#10) of 9 residents with pressure ulcers, out of a total sample of 24, to ensure that the resident who entered the facility without heel pressure ulcers, did not develop pressure ulcers. The facility also failed to ensure that necessary treatment and services was provided to promote healing of an existing pressure ulcer and prevent new pressure ulcers from developing. Findings include: Resident #10 was admitted to the facility in 12/2013 for rehabilitation with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment with a reference date of 12/31/13, indicated that the resident was cognitively impaired and was dependent on facility staff for activities of daily living including incontinence care, bed positioning and transfers. The resident was not coded with previous or existing pressure ulcers. The resident was coded as receiving physical, speech and occupational therapy services. The resident was assessed to be at high risk for potential skin breakdown with a Norton Plus score of 8 (a scale of 15 or less is identified as high risk). Review of the 12/24/13 skin care plan indicated that Resident #10 was at risk for skin breakdown. The care plan indicated that pressure relieving devices (devices not specified) were applied to the bed and the chair. In addition, incontinence care was to be provided by the certified nurse aide (CNA) every 2-3 hours along with daily skin checks. Weekly skin evaluations by licensed staff were scheduled for completion each Friday. Per 2/10/14 record review, a review of the weekly skin evaluations completed by licensed staff on 1/10/14, 1/17/14 and 1/24/14 assessed that the resident's skin was normal (intact). Review of a physical therapy (PT) assessment on 1/28/14 indicated that the resident had 2 open areas on the heels which the assessment indicated was reported to the nurses. Interview with the Occupational Therapist (OT) on 2/11/14 at 10:10 A.M., said that she was in the therapy room on 1/28/14 when the Physical Therapist (PT) told her that the resident was having trouble with his/her feet while attempting the parallel bars and together the OT and PT observed that the resident had open areas on both heels. Review of pressure ulcer care plan initiated on 1/28/14 indicated that the resident had a left inner heel pressure ulcer and a right heel stage I (a localized reddened) area. New orders on 1/28/14 included skin prep (skin barrier cream) to bilateral heels every shift, no shoes, foam booties at all times and for the resident to be seen by the wound care consultant. The 1/29/14 day shift nurse's note indicated that the resident was transferred (to Unit 2) at noon. The nurse indicated that the resident was wearing "booties" on both feet. The resident's right heel was assessed as red and intact and the left heel "open with dry skin flapping over edge" The resident had no complaints of pain. Review of the 1/30/14 Wound Care Initial Evaluation completed by the wound physician indicated that the resident had an "unstageable due to necrosis (tissue death) of the left heel of at least 7 days duration." The wound size was measured at 1 cm (centimeter) in length x 4 cm in width and depth not measurable due to 100 percent thick black necrotic (dead) tissue. No infection was identified. The wound physician recommended skin prep to the left heel daily and to off-load the wound (removal of pressure from the heels). Per the facility Pressure Ulcer Prevention Protocol: "Use devices to eliminate pressure on the heels. For short term use place pillows under the calf to raise the heels off the bed. Place in heel suspension boot or use heels up device for long term use." The protocol also indicated to reposition residents in the chair at least every hour and in bed at least every two hours. Review of the 1/31/14 weekly skin evaluation completed by the licensed nurse failed to identify that the resident had the heel ulcer and identified the skin evaluation as normal. During initial tour on 2/3/14 at approximately 9:30 A.M. Unit Manager (UM #2) said that Resident #10 was recently transferred from the 1st floor with bilateral heel wounds. UM #2 said the resident heels were to be off loaded with foam booties to be worn at times. On 2/4/14 at 7:55 A.M. the resident was observed lying in bed and positioned on his/her back with head of the bed slightly elevated and the bed in the low position. The sheet and blanket were observed lying alongside the resident's legs leaving the resident's lower body exposed. The resident told the surveyor that the "blankets were too heavy." The resident was observed with a foam bootie secured by velcro straps on the left heel. The foam boot was twisted to the side and the resident's left heel was resting directly on the mattress. No right heel foam bootie was observed and the resident's bare foot was resting directly on the mattress. The resident was visited by the wound consultant again on 2/6/14 who assessed that the resident's left heel wound as "improved evidenced by a decreased surface area." A wound observation was completed 2/10/14 at 11:30 A.M. with Unit Manager #2. Prior to entering the room UM #2 said that the physical therapist had reported earlier that morning that the Resident's left heel "looks worse today." UM #2 removed the resident's left heel bootie exposing the resident's bare heel. The inside of the bootie had approximately a dime sized amount of brown exudate. The left heel was observed with eschar covering a portion of the wound bed with lifting of the wound edge exposing pink tissue. Dry flaking skin was observed on the left heel and the foot. Two new reddened blanchable areas on the bony prominence of the left lateral foot and on the anterior ankle bone were observed. The resident's left great toe nail was black in color and the surrounding skin was red. UM #2 said that the blackened toe nail was not brought to her attention prior to the observation. The right heel bootie was removed and revealed intact skin on the right heel. A reddened area on the right foot hallux (later measured at 0.5 cm x 0.2 cm) was identified by UM #2 as new. UM #2 was asked during interview on 2/10/14 at 11:40 A.M. about existing interventions that were in place to provide pressure relief for Resident #10 especially since new pressure areas were observed. UM #2 said that the foam booties were ordered but was unable to explain how the resident heels were off loaded when in bed. UM #2 was unable to explain how pressure relief is provided to keep the resident's bony prominence's, such as the ankles, from direct contact with each other. UM #2 was unable to explain what interventions were implemented to reduce the weight of the blankets off of the resident's feet/toes. UM #2 reviewed existing documentation with the surveyor said that there was no documented evidence of a turning or repositioning schedule for Resident #10 while in the bed or the wheel chair as per the pressure ulcer prevention protocol. UM #2 said that she would contact the physician for additional orders. Following surveyor inquiry on 2/10/14 the physician gave new orders for a air mattress, foot cradle and the application of bilateral multipodus boots.