Every finding on record at Brandon Woods of Dartmouth

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment in two of three nourishment kitchenettes. Findings include:Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to:3-302 Preventing food and ingredient contamination; (A) FOOD shall be protected from cross contamination by: (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11;3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (E) In a clean, protected location if the UTENSILS, such as ice scoops, are used only with a FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD;Review of the facility's policy titled Housekeeping, undated, indicated but was not limited to the following:-Standards for routing cleaning of all interior spaces will be followed, including, but not limited to, diet kitchens.-The housekeeping/Laundry Supervisor will: -ensure cleanliness of all interior areas -be familiar with regulations relating to cross contamination and the spread of infectious diseases and shall train staff and monitor compliance.On 4/14/26 at 9:56 A.M., the surveyor made the following observations of the Two North Unit nourishment kitchenette:- Brown/orange food splatter/residue was noted to the top, sides, and bottom of the inner portion of the microwave. The glass plate had brown food splatter/residue all along the edges of glass.-Large amounts of dried food residue were observed on the inner portion, on the top, on the side and underneath the toaster oven. On 4/15/26 at 10:07 A.M., the surveyor made the following observations of the Two North Unit nourishment kitchenette:- Brown/orange food splatter/residue was noted to the top and sides of the inner portion of the microwave.On 4/21/26 at 9:51 A.M., the surveyor made the following observations of the Two North Unit nourishment kitchenette:- Brown/orange food splatter/residue was noted to the top, sides, and bottom of the inner portion of the microwave. The glass plate had brown food splatter/residue all along the edges of glass. In the center of the bottom of the microwave, under the glass plate and plastic carousal wheel was noted to have a brown liquid pooled. -Large amounts of dried food residue were observed on the inner portion, on the top, on the side, and underneath the toaster oven. -The ice scoop was observed sitting in a holder noted to have brown residue on the inside walls of the holder. The inside bottom of the holder had a large amount of stagnant water with a milky white film floating on the water with particles floating in the water. On 4/21/26 at 10:00 A.M., the surveyor made the following observations on Unit One nourishment kitchenette:- Brown/orange food splatter/residue was noted to the top and sides of the inner portion of the microwave.-White residue was noted on the sides of the ice scoop holder. The ice scoop holder was observed to have water with white floating residue on the inside bottom of the holder with the ice scoop resting in the water.-Large amounts of dried food residue were observed on the inner portion, on the top, on the side, and underneath the toaster oven. During an interview on 4/21/26 at 10:12 A.M., the Food Service Director (FSD) said dietary staff are responsible for daily stocking and cleaning the refrigerators of the nourishment kitchenettes. The FSD said the dietary staff are also responsible for the ice process for the kitchenettes which includes maintaining and cleaning the ice coolers and the ice scoop/reservoir holders. The FSD said the dietary staff provide ice to the units three times a day and provide a new ice scoop at about 11:00 A.M. each day. The FSD said housekeeping is responsible for cleaning all other areas of the nourishment kitchenettes to include the microwaves, toasters and counters. The FSD said the reservoir that holds the ice scoop should have been cleaned daily and the ice scoop should not have been sitting in old water.During an interview on 4/21/26 at 10:24 A.M., the Housekeeping Manager (HM) said the housekeeping department is responsible for the cleanliness of all unit kitchenettes. The HM said the housekeeping team members clean the kitchenettes a few times a day. The HM said the housekeepers should have cleaned the microwaves, toaster ovens, and wiped down counters each time cleaning was completed and that was not done.During an interview on 4/21/26 at 1:14 P.M., the Administrator and the surveyor reviewed the observations of the nourishment kitchenettes. The Administrator said all equipment should have been cleaned. The Administrator said housekeeping is responsible for the overall cleaning to include the microwaves and toaster ovens and dietary is responsible for the cleaning of refrigerators, ice delivery, and ice equipment. The Administrator said he does not have a policy for ice delivery and storage of ice equipment.

Based on observations, interviews, and document review, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in two of three medication carts observed. Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, dated as revised 6/30/25, indicated but was not limited to:-Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened.-When an ophthalmic solution or suspension has a manufacturer shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container. 1. On 4/15/26 at 3:41 P.M., the surveyor observed the #6 Medication Cart with Nurse #2 on Two South. The surveyor observed one bottle of Latanoprost eye drops (used to treat increased pressure in the eye) opened and stored in the box, neither the bottle nor the box was labeled with an open or use by date. Further review of the Latanoprost box indicated it had been filled by the pharmacy on 12/11/25. Review of the Latanoprost packaging indicated but was not limited to:- Once a bottle is opened for use, it may be stored at room temperature for 6 weeks. During an interview on 4/15/26 at 3:45 P.M., Nurse #2 said she could not say when the bottle of Latanoprost was opened or when it should be thrown away because it was not labeled. Nurse #2 said eye drop bottles should be labeled with the open date when they are opened. 2. On 4/15/26 at 4:01 P.M., the surveyor observed the #4 Medication Cart with Nurse #3 on Two North. The surveyor observed one Breyna inhaler (used to decrease inflammation in the lungs) out of the foil pouch and stored inside the box, neither the inhaler nor the box was labeled with an open or used by date. Further review of the Breyna inhaler box indicated it had been filled by the pharmacy on 10/2/25. Review of the Breyna packaging indicated but was not limited to:-Discard the inhaler when the labeled number of inhalations have been used or within three months of opening the foil pouch During an interview on 4/15/26 at 4:04 P.M., Nurse #3 said she could not say when the inhaler was opened because it was not labeled. Nurse #3 said inhalers should be labeled with the open or use by date when they are first opened. During an interview on 4/16/26 at 12:33 P.M, the Director of Nursing (DON) said medications with a shortened expiration date should be labeled with the open and discard date upon opening.

Based on observation, interview, and document review, the facility failed to develop and implement an individualized care plan for one Resident (#5), who had documented non-compliance with an ordered cervical neck collar to treat a fracture of the 7th cervical vertebrae, out of a total of 21 residents. Findings include: Review of the facility's policy titled Care Planning - Comprehensive, dated as revised 5/2025, indicated but was not limited to the following: - purpose: an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident- each comprehensive care plan is designed to: incorporate identified problem areas and associated risk factors, reflect expressed wishes and treatment goals, aid in preventing or reducing declines in the resident's functional status or levels, enhance optimal functioning, and reflect currently recognized standards of practice - identify problem areas and their causes and develop targeted and meaningful interventions- care plan interventions address the underlying source of the problem areas, rather than addressing only the symptom or trigger- assessment is ongoing and care plans are revised as information about the resident's condition change Resident #5 was admitted to the facility in January 2026 and had diagnoses including: wedge compression fracture of the third lumbar vertebrae, cognitive communication deficit, and compression fracture of the seventh vertebrae (C7). Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, had behaviors of rejecting care, and a history of falls. Review of the current Physician's Orders for Resident #5 indicated but were not limited to the following:- Keep cervical collar in place at all times, every shift. Check every shift for placement and check skin integrity (3/31/26)Review of the progress and treatment notes for Resident #5 from April 1st through April 21st 2026 indicated a total of 18 times the Resident demonstrated non-compliance or removal of his/her cervical neck brace. Throughout the survey, the surveyor made the following observations of Resident #5 without his/her cervical collar in place: -4/16/26 at 8:05 A.M. Resident in bed with the cervical collar lying next to the Resident on the bed, not securing his/her neck.-4/18/26 at 10:45 A.M. and 12:17 P.M., Resident in bed with cervical collar on the bedside table, not securing his/her neck.During an interview on 4/21/26 at 8:25 A.M., Certified Nursing Assistant (CNA) #4 said Resident #5 is resistive to the cervical neck collar mostly when he/she is in bed and will attempt to self-remove the device and if successful push staff away if they attempt to replace it. She said the neck collar is for a neck fracture and when she finds the Resident without the collar in place she notifies the Nurse. During an interview on 4/21/26 at 8:50 A.M., Nurse #9 said the Resident can be resistive to wearing the cervical collar and will pull on the collar or self-remove it at times. She said when that happens, they just attempt to re-educate the Resident and put the collar back in place. During an interview on 4/21/26 at 8:55 A.M., Unit Manager #2 said Resident #5 is known to self-remove their cervical collar at times and this has been on ongoing behavior. She said she in not sure about a care plan for this refusal or behavior, but she would have to look into that.During an interview on 4/21/26 at 9:06 A.M., Rehab staff #1 said she knows Resident #5 well and the Resident pulls on the cervical collar or attempts to remove it frequently. She said they attempt to train the Resident on the importance of leaving the collar in place, but because the Resident's cognition fluctuates this is a challenge. During an interview on 4/21/26 at 9:10 A.M., Rehab staff #2 said the Resident started wearing the cervical collar following a fall in March of 2026 which resulted in a cervical fracture. She said Resident #5 does attempt to remove the collar or tug on it during rehab treatments and had to be redirected to leave the collar in place. She said although the Resident seemed reluctant to leave the collar in place during rehab treatments it does not get removed. She said there had been times that she had gone to collect the Resident for therapy and found the cervical collar not in place and had to alert the Nurses to the situation at that time so they can follow up as needed. Review of the current care plans in place for Resident #5 indicated but were not limited to the following: PROBLEM: At Risk for falls related to (r/t) recent decline r/t recent hospitalization (3/10/26)INTERVENTIONS: PT/OT screens as needed, labs, assess for risk, encourage rest periods (3/10/26); perimeter mattress (3/13/26); mats on floor next to the bed (3/31/26); bed alarm/chair alarm (4/2/26) PROBLEM: Behavior, alteration in r/t socially inappropriate (3/19/26)INTERVENTIONS: medicate as ordered (a/o), psych services a/o, offer drink/snack, diversional activity, assess to determine unmet need, identify potential triggers to escalating behavior, offer alternative ways to cope, monitor behavior episodes every shift, monitor for changes in behavior and notify physician of changes (3/19/26) PROBLEM: Fracture, C7, risk for complications/strengths (4/2/26)INTERVENTIONS: PT/OT screens, assess for odors from immobilizer and notify physician as needed (PRN), observe for non-verbal indicators of discomfort and intervene accordingly (4/2/26) The care plans failed to identify the behavior of non-compliance and pulling at the cervical collar or how to intervene in the event the cervical collar is not used as ordered even though the staff were aware this was occurring. During an interview on 4/21/26 at 10:03 A.M., the Director of Nurses said the Resident returned from the emergency room on 3/31/26 with orders for the cervical neck collar to be in place at all times. She said Resident #5 had been resistant to wearing the collar consistently and began self-removing the device. She reviewed the medical record and care plans with the surveyor and said there should be individualized information in the care plan regarding the Resident's behavior and non-compliance and what to do if the Resident declines the collar and none of that information is there. She said the care plans were not individualized to the Residents' current situation. During an interview on 4/21/26 at 10:32 A.M., NP #1 said she was not aware of the Resident's refusal to wear the cervical collar until recently and she instructed them at that time to reach out to the orthopedic spine specialist and notify them for possible interventions and to ensure there would be no negative impact on the Resident. She said she believed Nurses should be documenting behaviors, changes and interventions for this specific situation but she was unsure how that information transferred to a care plan because she had nothing to do with that process. A telephone call was placed to the Attending physician for Resident #5 on 4/16/26 at 3:35 P.M., but at the time of posting no return call had been received.

Based on observation, interview, and document review, the facility failed to ensure an ordered fluid intake restriction of 1500 milliliters (ml) a day was documented, monitored, and followed, for one Resident (#1) to maintain proper hydration and health, out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Encouraging and Restricting Fluids, dated as revised October 2010, indicated but was not limited to the following:- the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health- verify physician order and review care plan- record fluid intake on the intake and output record, record intake in milliliters (ml)- be accurate when recording fluid intake- if resident refuses, document the reasons why and the interventions taken Resident #1 was admitted to the facility in January 2026 and had diagnoses including End stage renal disease and dependence on renal dialysis. Review of the current orders for Resident #1 indicated, but were not limited to the following: Diet: House, No saltshaker renal - breakfast lunch and dinner, minced moist scrambled eggs for breakfast, thin 1500ml fluid restriction (2/22/26)Nepro with Carbsteady 240ml twice a day oral at 10:00 A.M. and 6:00 P.M. (2/6/26) Review of the current care plans for Resident #1 indicated but were not limited to the following: PROBLEM: Requires a mechanically altered diet (1/23/26)GOAL: Resident will exhibit good tolerance of mechanically altered diet as evidenced by (aeb) no episodes of choking, pocketing, significant weight changes, or alterations in fluid balance (1/23/26)INTERVENTIONS: Provide diet as ordered (a/o), observe for changes in ability to tolerate mechanically altered diet, allow time for meal consumption (1/23/26) PROBLEM: Resident is at potential nutritional risk related to (r/t) weight less than ideal body weight, possible weight shifts with hemodialysis treatment, need for therapeutic and texture modified diet (2/2/26)GOAL: By mouth (po) and supplement intake greater than or equal to 50% weight stability; gradual gain is desirable (2/2/26)INTERVENTIONS: Continue diet a/o, recommend 1500ml fluid restriction, monitor weights skin labs, Nepro supplement recommended twice a day (BID) to optimize/support intake (2/2/26) PROBLEM: Hemodialysis; Potential for complications (1/23/26)GOAL: Resident will have signs and symptoms of complications identified immediately with appropriate interventions daily (1/23/26)INTERVENTIONS: Monitor labs a/o, provide therapeutic diet a/o, encourage resident to maintain compliance with dietary restrictions, provide education on the reasons for restrictions and the potential effects of non-compliance, instruct resident to report headaches chest pain and change in mental status and observe and report non-verbal signs of the same, monitor vascular access device for redness drainage signs of infection, notify physician as needed (1/23/26) The current physician's orders and care plans for Resident #1 failed to indicate how the fluid restriction of 1500ml a day would be broken down and divided between dietary and nursing and how the restriction would be monitored and documented. During an interview with observation on 4/16/26 at 8:20 A.M., the surveyor observed Certified Nursing Assistant (CNA) #3 assisting Resident #1 with his/her breakfast. Review of the tray ticket on the tray failed to indicate that the Resident was on a 1500ml fluid restriction. CNA #3 said the Resident was an assist and she believed he/she was on a fluid restriction. She said the amount would have to be verified with the nurse. She said the CNAs are supposed to document fluid intake on the paper intake and output (I&O) sheets at the nurses' station or in the electronic system. The surveyor observed that the Resident's tray contained one 120ml cup of apple juice, a 120ml of coffee and 120ml of milk. CNA #3 said the Resident's intake does fluctuate, but he/she does not typically request more fluids and if he/she did, she would alert the nurse. Review of the I&O book on the unit failed to indicate Resident #1 had an I&O sheet for the staff to document his/her fluid intake each shift. Review of the point of care (POC) CNA documentation for fluid intake each shift in the electronic record for Resident #1 indicated fluid intake was documented 7 out of 46 opportunities for the month of April 2026. During an interview on 4/16/26 at 10:22 A.M., Unit Manager #2 reviewed Resident #1's medical record with the surveyor. She said the Resident does have an order for a 1500ml fluid restriction, but there is no breakdown indicating how the fluids would be split up between dietary and nursing and there is no I&O sheet for the Resident for the fluids to be monitored. She said the POC system does have some fluid intake documented but it is inconsistent and those documents are not monitored by the nurses to ensure the Resident does not exceed the prescribed fluid restriction. She said typically fluid restriction orders are broken down and placed in the system for the nurses to sign off an amount not to be exceeded each shift and the CNAs complete an I&O sheet so the total amount can be calculated for the 24-hour period to ensure the fluid restriction is maintained. She said it appears at this time that was not happening for Resident #1 and there was no documentation to show whether the fluid restriction had been maintained or monitored. Review of the Fluid Restrictions (general guidelines) sheet provided by the facility dietitian, indicated but was not limited to the following: 1500ml Fluid restrictionBreakfast 360ml, Lunch 360ml, Dinner 300ml for a total of 1020mlLeave 240ml for nourishments and 240ml for med pass During an interview on 4/16/26 at 11:52 A.M., Dietitian #1 reviewed the fluid restriction breakdown sheet with the surveyor and said the sheet is the standard breakdown she uses for all residents in the facility on a 1500ml fluid restriction. She said she knows Resident #1 well, he/she is on dialysis and is on a 1500ml fluid restriction since about February 5th of this year. She said she does not monitor the fluid restrictions or follow up on them for accuracy and had no way of doing that. She said she recommended a supplement drink of Nepro 240ml for the Resident around 2/6/26 and the Resident gets that twice a day. She said that fluid would count in the nursing portion of the fluid restriction for nourishments and med pass. She said she assumed the nurses would know not to provide other fluids than the Nepro supplement since all other fluids in the fluid restriction would come from the kitchen. She said she communicates with the dietitian at the dialysis center about weekly, but she does not know if that dietitian tracks or monitors the Resident's fluid restriction. During an interview on 4/16/26 at 12:06 P.M., the Food Service Director said that anyone on a fluid restriction would have that information indicated on their meal ticket. She provided the surveyor with a meal ticket print out for Resident #1, and said the Resident is not on a fluid restriction to her knowledge. She reviewed all dietary notation forms provided to the dietary department from the nursing department for Resident #1 and said there was only one form available from 2/17/26, and it did not indicate the Resident was on a fluid restriction. On review of the dietary notation form the communication indicated the Resident had a diet change to minced moist texture but failed to indicate the 1500ml fluid restriction. She reviewed the orders for the Resident in the medical record and said the Resident was supposed to be on a fluid restriction since February 2026, but she was unaware of that since she never received communication of that and that is why the Resident did not have his/her fluid restriction noted on their dietary tray ticket. During an interview on 4/16/26 at 12:22 P.M., Nurse #4 said Resident #1 takes their meds in applesauce or pudding with either water or juice. She said the Resident gets a Nepro supplement twice a day, but that is not typically given with his/her medications. She said she was unsure of where in the fluid restriction breakdown the Nepro supplement would be counted and would have to look into that information. During an interview on 4/16/26 at 1:31 P.M., Dietitian #2 said she is the dietitian at Resident #1's dialysis center and knows the Resident well. She said she communicates with the facility dietitian about weekly, but if she was recommending a change to a diet order, fluid restriction, or supplements she would send that information directly to the nursing staff. She said she was not involved with how a fluid restriction was provided by the facility, and she does not monitor the fluid intake or restriction documentation. She said she monitors the Resident by interdialytic weights. She said her expectation was that when a fluid restriction was recommended for a resident that the facility was ensuring it was followed as ordered for optimal resident outcomes. During an interview on 4/16/26 at 4:15 P.M., CNA #5 said she was not aware that Resident #1 was on a fluid restriction. She said she does assist the Resident with their dinner meal, and he/she tends to consume all the provided fluids, but she wasn't sure if the Resident receives any additional snacks or fluids throughout the evening shift. During an interview on 4/16/26 at 4:19 P.M., CNA #6 said she knows Resident #1 but was not aware he/she was on a fluid restriction. During an interview on 4/16/26 at 4:26 P.M., Nurse #1 said Resident #1 is assisted with his/her meals. She said the Resident takes their medications crushed in pudding with either juice or ginger ale to wash them down. She said the Resident does have a supplement order that is twice a day and that is consumed in varying amounts. She said she was not aware of all the details of the fluid restriction, but the Resident does not typically request any additional fluids. During an interview on 4/17/26 at 8:30 A.M., the Director of Nurses said when a recommendation is received for a resident to be placed on a fluid restriction it is approved by the physician or Nurse practitioner and then the order is placed on the medication administration record with a maximum amount that can be received by each shift. Then, it is to be signed off by the nurse to ensure that amount has not been exceeded each shift and a care plan is created. She said the CNAs complete an I&O sheet documenting the amounts per shift and that is how the fluid restriction is monitored to ensure compliance is maintained. She said the documentation for monitoring Resident #1's fluid intake was not occurring and there was no way to demonstrate whether the Resident was following his/her fluid restriction of 1500ml daily. She said she would expect that the dietitian would have noticed the documentation was missing and be monitoring this side by side with nursing. She said she was not aware that any supplements would be counted in the total amount for nursing and this Resident's supplement was not timed to be provided only when medications were received. She said I &O sheets should have been implemented and completed for Resident #1. She said there was some work to be done in this area to ensure all the pieces were in place. During an interview on 4/21/26 at 10:34 A.M., Nurse Practitioner #1 said Resident #1 was on a 1500ml fluid restriction and her expectation would be that the facility was documenting the fluid intake each shift or day to ensure the fluid restriction was followed and the Resident was not exceeding the prescribed amount of fluid daily.

Based on observation, interview, and record review, the facility failed to notify the physician or clinician in a timely manner when one Resident (#5) had a change in their compliance with their treatment of wearing an ordered neck collar at all times to treat a new cervical fracture, out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Resident Change in Condition, undated, indicated but was not limited to the following: The purpose is to facilitate nursing response for residents exhibiting a change in condition and to define requirements for notification of change- whenever there is a change in the resident's condition the nurse will follow protocols- prior to contacting the physician, the nurse will conduct a clinical assessment and collect pertinent information to report to the physician- a change in condition will be documented in the nurses' notes and other areas of the medical record Resident #5 was admitted to the facility in January 2026 and had diagnoses including wedge compression fracture of the third lumbar vertebrae, cognitive communication deficit, and compression fracture of the seventh cervical vertebrae. Review of the Minimum Data Set (MDS) assessment, dated 3/26/26, indicated Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status score of 3 out of 15, had behaviors of rejecting care, and a history of falls. On 4/14/26 at 9:30 A.M., the surveyor observed the Resident sitting on the edge of their bed leaning to one side with a hard collar neck brace in place. Nurse #4 was alerted to the situation and assisted the Resident. She said the Resident is confused and had been declining a little bit and to the best of her knowledge had to wear the neck brace related to a fall which resulted in a neck fracture. Review of the current Physician's Orders for Resident #5 indicated but were not limited to the following: -Keep cervical collar in place at all times, every shift. Check every shift for placement and check skin integrity (3/31/26)Review of the April 2026 Treatment Administration Record (TAR) (4/1/26-4/21/26) indicated the cervical collar was either held or otherwise not in place as ordered for 15 of 61 opportunities starting on 4/3/26. During an interview on 4/16/26 at 7:59 A.M., Unit Manager #2 said Resident #5 had an overall cognitive decline since admission and had fluctuating behaviors including yelling and being uncooperative related to his/her confusion. Throughout the survey the surveyor made the following observations of Resident #5 without his/her cervical collar in place: -4/16/26 at 8:05 A.M.- Resident in bed with the cervical collar lying next to the Resident on the bed, not securing his/her neck.-4/18/26 at 10:45 A.M. and 12:17 P.M., Resident in bed with cervical collar on the bedside table, not securing his/her neck as ordered. During an interview on 4/21/26 at 8:50 A.M., Nurse #9 said the Resident can be resistive to wearing the cervical collar and will pull on the collar or self-remove it at times. She said when that happens, they just attempt to re-educate the Resident and put the collar back in place. During an interview on 4/21/26 at 8:55 A.M., Unit Manager #2 said Resident #5 is known to self-remove their cervical collar at times and this has been an ongoing behavior. She said she was not sure about the physician being notified when the behavior occurs, but they should be and she would have to look at the record and get back to the surveyor. Review of the treatment and nursing progress notes for Resident #5 from 4/1/26 through 4/21/26 indicated the Resident refused to wear the cervical neck collar and was non-compliant with its use on the following dates and times:4/3/26: 9:02 P.M.4/4/26: 1:31 A.M. and 7:07 P.M.4/7/26: 10:12 A.M.4/8/26: 3:52 A.M. 4/9/26: 1:53 A.M.4/10/26: 4:34 A.M. and 11:41 A.M.4/11/26: 5:10 A.M.4/12/26: 9:55 A.M.4/15/26: 3:20 A.M.4/16/26: 6:26 A.M.4/17/26: 7:26 A.M.4/18/26: 4:58 A.M.4/19/26: 8:27 A.M., 4:34 P.M., and 10:15 P.M4/20/26: 11:57 A.M. Further review of the treatment and progress notes failed to indicate the Attending Physician or the Nurse Practitioner (NP) were made aware of this change in the Resident's compliance with their ordered brace and behavior. The note on 4/20/26 indicated a call was placed to the orthopedic specialist but no call back had occurred. During an interview on 4/21/26 at 10:03 A.M., the Director of Nurses said the Resident returned from the emergency room on 3/31/26 with orders for the cervical neck collar to be in place at all times. She said Resident #5 had been resistant to wearing the collar consistently and began self-removing the device. She said when this first started occurring the staff should have notified the Physician or NP to prevent any possible complications and receive possible orders for further intervention. She reviewed the medical record with the surveyor and said the behavior of non-compliance with the cervical collar started on 4/3/26 and the physician should have been made aware at that time, but there is no documentation that indicated the attending physician, NP or orthopedic spine specialist was contacted at all until 4/20/26 and at that time only a message was left. She said the expectation was the staff would have notified the physician when this change in the Resident's compliance occurred and the behavior developed and she does not see that that happened. Review of the clinician progress notes for April 2026 failed to indicate any of the Physicians, NPs or Physician assistants had been notified of Resident #5's non-compliance with their cervical collar. During an interview on 4/21/26 at 10:32 A.M., NP #1 said she was not aware of the Resident's refusal to wear the cervical collar until recently (on or around 4/15/26) and she instructed the staff at that time to reach out to the orthopedic spine specialist and notify them for possible interventions and to ensure there would be no negative impact on the Resident. She said at this point she would expect that they had spoken with someone from the specialist's office and received further instruction or documented the follow up. She said since the order is currently in place for the cervical collar to be on at all times her expectation was that the order is being followed as written and if it cannot be for any reason then the facility staff would have notified herself or one of her colleagues immediately for intervention or guidance. She said on review of the progress notes from her colleagues and herself she could not locate any evidence that anyone of the Attending clinicians had been made aware of this change in the Resident's behavior or compliance with the cervical collar. A telephone call was placed to the Attending physician on 4/16/26 at 3:35 P.M., and the Orthopedic Spine specialist on 4/21/26 at 10:25 A.M., for this Resident but at the time of posting no return call had been received.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had a diagnosis of Dysphagia (difficulty swallowing), and required an altered textured diet, the Facility failed to ensure that he/she remained as free from hazards as is possible, when on 03/04/26, Resident #1 was served his/her lunch time meal tray with a food item that was inconsistent with his/her diet orders, he/she consumed it, started to choke and required staff intervention to help expel the food. Findings Include: Review of the Facility's Policy titled Food and Nutrition Services, dated as revised October 2017, indicated the following:-each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs-food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident-if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/05/26, indicated that on 03/04/26, at approximately 12:15 P.M. Nurse #1 heard a resident in the dayroom on Resident #1's unit ask if he/she (Resident #1) was choking? The Report indicated Nurse #1 immediately ran to the day room, asked Resident #1 if he/she was choking, he/she nodded yes, and Nurse #1 successfully performed the Heimlich Maneuver (abdominal thrusts, life-saving first-aid technique for choking when a person cannot breathe, speak or cough, effectively dislodging items using upward pressure) on him/her. The Report indicated that Nurse #1 assessed Resident #1, he/she exhibited normal breathing, and his/her vital signs were stable. The Report further indicated that Resident #1's lunch meal was not prepared by dietary staff according to his/her diet order, and that nursing staff had not checked his/her meal tray for accuracy according to his/her meal ticket and he/she was served the incorrect meal texture. Resident #1 was admitted to the Facility in December 2025, diagnoses included dysphagia (difficulty swallowing), parkinsonism (neurological syndrome characterized by slow movement, rigidity and tremors), dysarthria (slurred, slow or mumbled speech), cerebral infarction (ischemic stroke caused by blocked blood flow to the brain), hyperlipidemia (high cholesterol), and anxiety. Review Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was moderately cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact). Review of Resident #1's Physician's Orders, dated February 2026, indicated he/she required a House diet, ground texture with nectar thick liquids. Review of Resident #1's Lunch meal ticket, dated 03/04/26, indicated that he/she required a House ground diet with nectar thick liquids.However, review of the facility lunch menu for 03/04/26, indicated the following meal was being prepared that day and therefore Resident #1 was served:-Chicken parmesan [not ground], spaghetti noodles, cauliflower and garlic bread knot.Review of Resident #1's Nurse Progress Note, dated 03/04/26, (written by Nurse #3), indicated that at approximately 12:15 P.M., Resident #1 was sitting in the secondary dining room (also known as the dayroom) eating lunch with another resident. The Note indicated Nurse #3 heard a resident in the room ask Resident #1 if he/she was choking, she ran into the room and asked Resident #1 are you choking? and he/she nodded yes. The Note indicated the Heimlich Maneuver was performed with success, Resident #1 began breathing and he/she was able to speak in full complete sentences. The Note further indicated that Resident #1's skin was warm, dry, and pink, his/her vitals were taken, and the Physician, Resident #1's Health Care Proxy (HCP) and the Administrator were notified of the incident.During an interview on 03/30/26 at 4:06 P.M., (which included review of her written statement), Nurse #3 said she worked the 6:00 A.M. to 2:30 P.M. shift on 03/04/26. Nurse #3 said around 12:15 P.M. she was sitting at the nurses' station across from the secondary dining room with Nurse #2 and Nurse #1 when she heard a resident (exact name unknown) say to Resident #1 are you choking? Nurse #3 said she looked at Resident #1, saw him/her doing the universal choking sign (person clutches one or both hands to their throat), so she immediately ran into the dining room and asked Resident #1 are you choking?' and he/she nodded yes.Nurse #3 said she got behind Resident #1, performed the Heimlich Maneuver on him/her and a piece of chicken was expelled from his/her mouth. Nurse #3 said Resident #1 took a deep breath in, was able to speak in full sentences and Resident #1 said he/she was okay. Nurse #1 said Resident #1's vital signs were taken and she notified the Administrator.Nurse #3 said she observed Resident #1's lunch tray which had chicken parmesan on it and the chicken had been cut up into pieces [not ground]. Nurse #3 said she did not know what Resident #1's diet order was, so she looked it up, and she saw that he/she had an order for a ground diet but had been given a regular texture diet.Nurse #3 said she did not know if Nurse #2 or Nurse #1 had checked Resident #1's meal tray prior to him/her being served his/her meal because she was not on the unit at the time the food truck had been delivered. Nurse #3 said nurses are responsible to check all residents' meal trays against their meal tickets prior to them being passed to a resident to ensure they receive the correct diet order.During an interview on 03/24/26 at 2:25 P.M., (which included review of her written statement), Nurse #1 said she worked the 6:00 A.M. to 2:30 P.M. shift on 03/04/26. Nurse #1 said she was at the nurses' station with Nurse #2 and Nurse #3 when she heard a resident in the dayroom ask Resident #1 are you choking? Nurse #1 said she and Nurse #3 immediately ran into the dayroom, they asked Resident #1 are you choking?' and he/she nodded yes. Nurse #1 said Nurse #3 got behind Resident #1, performed the Heimlich Maneuver and he/she expelled chewed up food. Nurse #1 said Resident #1 was able to breathe and said he/she was okay. Nurse #1 said Resident #1 had an order for a ground diet and that she observed that the chicken on his/her lunch plate was cut up into pieces, not grounded up, as it should have been. Nurse #1 said she knew the nurses were supposed to check all residents' meal trays for accuracy against their meal tickets to ensure they receive the correct diet texture. Nurse #1 said she had not checked Resident #1's or any of the other resident's meal trays for accuracy that day.During an interview on 03/25/26 at 10:50 A.M., (which included review of her written statement), Nurse #2 said she worked the 6:00 A.M. to 2:30 P.M. shift on 03/04/26. Nurse #2 said when the food trucks are delivered to the units, nurses must check all residents' meal trays against their meal tickets so that they match what is on their tray before being passed to residents to ensure they are receiving the correct diet texture. Nurse #2 said she had not checked Resident #1's meal tray or any other residents' tray that day.During an interview on 03/24/26 at 1:51 P.M., (which included review of her written statement), Certified Nurse Aide (CNA) #1 said she worked the 6:00 A.M. to 2:30 P.M. shift on 03/04/26 and helped pass lunch trays that day. CNA #1 said she could not recall if the nurses on the unit had checked the resident's meal trays on the food trucks that day, prior to helping them pass them out. During an interview on 03/24/26 at 2:06 P.M., (which included review of her written statement), CNA #2 said on 03/04/26 she was behind doing morning care to her assigned residents when the food tucks for lunch were delivered to the unit. CNA #2 said she helped pass lunch trays that day. CNA #2 said she saw CNA #1 and CNA #3 passing out the meal trays and asked them if the nurses had checked the meal trays and that both CNA #1 and CNA #3 had said yes.During a telephone interview on 03/30/26 at 1:09 P.M., the Former Administrator said on 03/04/26 Nurse #3 informed him that Resident #1 had choked on his/her lunch meal, that she (Nurse #3) performed the Heimlich Maneuver on him/her, he/she had expelled some food and said he started an investigation right away. The Former Administrator said he interviewed the nurses working (Nurse #1, Nurse #2, and Nurse #3) on the unit the day of the incident and determined that the nurses had not checked Resident #1's meal tray or any other residents' tray at lunch prior to them being passed to residents. The Former Administrator said he could not determine which staff member gave Resident #1 his/her lunch tray but said that nurses were responsible and supposed to check all meal trays for accuracy prior to meals being served to a resident, and that the meals are accurate according to the resident's meal ticket.During an interview on 03/25/26 at 2:56 P.M., the Director of Nursing (DON) said on 03/04/26 the Former Administrator notified her that Resident #1 had a choking incident at lunch time and one of the nurses (identified as Nurse #3) had to perform the Heimlich Maneuver.The DON said the Dietary Department had sent the wrong diet texture order for Resident #1 and that the nurses on the unit had not checked Resident #1's meal tray against his/her meal ticket before he/she was served the meal.The DON said nurses were responsible for checking all residents' meal trays according to the resident's meal ticket to ensure they receive the correct meal and that it is her expectation that all nurses check residents' meal trays before being passed to them.On 03/25/26, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction with an effective date of 03/06/26, which addressed the area(s) of concern as evidenced by:A. On 03/04/26, Resident #1 was assessed by the nurse, the physician was notified, and a new order was obtained for a chest X-ray. Resident #1 returned to his/her baseline following the incident and had no further complaints.B. On 03/04/36 Resident #1 was evaluated by the Speech Language Pathologist and seen six days during 03/04/36 through 03/13/26 with recommendations to continue ground diet and no waffles or pasta.C. On 03/05/26, the Unit Managers conducted a house wide audit on all units: to ensure all residents' meal trays were checked for accuracy according to their diet order on their meal tickets prior to meal service.D. On 03/04/26, the Staff Development Coordinator initiated and provided education to all Licensed Nursing Staff on checking residents' meal trays for accuracy according to their meal ticket prior to meal service: all Licensed nurses are to check all meal trays to ensure the correct diet on the meal ticket matches the meal.E. On 03/05/26, the Food Service Director provided education to all Dietary staff on checking meal trays for meal accuracy: all resident meal trays must be checked for accuracy during meal service to ensure that each meal plated is accurate according to each resident's diet orders/texture on their meal tickets.F. On 03/05/26, the Dietary Department Management started daily audits on all residents' meal trays for accuracy according to their meal tickets.G. The Nursing Department Staff will continue to conduct audits on resident's meal trays for accuracy according to their diet orders on the meal tickets daily for seven days, then weekly for four weeks, then monthly for a minimum of two QAPI cycles.H. The Dietary Department Management will continue to conduct audits on residents' diet orders on the meal tickets are accurate to the meal tray being served daily for seven days, then weekly for four weeks, then monthly for a minimum of two QAPI cycles.I. The results of the audits will be presented and reviewed at the quarterly QAPI meeting for a minimum of two quarters or until substantial compliance is achieved.J. The Director of Nursing, Food Service Director, and/or designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of dysphagia (difficulty swallowing) and required an altered (ground) texture diet, the Facility failed to ensure meals prepared and served to him/her met his/her individual needs and physicians order for diet, when on 03/04/26 dietary staff preparing his/her lunch time meal tray did not put the correct texture of food on his/her tray, he/she tried to consume it and experienced a choking episode.Findings Include: Review of the Facility's Policy titled Food and Nutrition Services, dated as revised October 2017, indicated the following:-Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs-food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident-if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/05/26, indicated that on 03/04/26, at approximately 12:15 P.M. Nurse #1 heard a resident in the dayroom on Resident #1's unit ask if he/she was choking? The Report indicated Nurse #1 immediately ran to the day room, asked Resident #1 if he/she was choking, he/she nodded yes, and Nurse #1 successfully performed the Heimlich Maneuver on him/her. The Report indicated that Nurse #1 assessed Resident #1, he/she exhibited normal breathing, and his/her vital signs were stable. The Report further indicated that Resident #1's lunch meal was not prepared by dietary staff according to his/her diet that nursing staff had not check his/her meal tray for accuracy according to his/her meal ticket and he/she was served the incorrect meal texture. Resident #1 was admitted to the Facility in December 2025, diagnoses included dysphagia (difficulty swallowing), parkinsonism (neurological syndrome characterized by slow movement, rigidity and tremors), dysarthria (slurred, slow or mumbled speech), cerebral infarction (ischemic stroke caused by blocked blood flow to the brain), hyperlipidemia (high cholesterol), and anxiety. Review of Resident #1's Physician's Orders, dated February 2026, indicated he/she required a House diet, ground texture with nectar liquids. Review of Resident #1's Lunch meal ticket, dated 03/04/26, indicated that he/she required a House diet, ground with nectar thick liquids.Review of the Facility's Dietary Menu, dated 03/04/26, indicated the following meal was on the menu to be prepared and served for lunch:-Chicken parmesan, spaghetti noodles, cauliflower and garlic bread knot.During an interview on 03/24/26 at 1:15 P.M., the [NAME] said the Dietary Aide assigned to the food truck calls out resident's diet orders from their meal tickets to the Cook. The [NAME] said he prepares the resident's meal plate according to the diet order called out by the Dietary Aide then hands the plate to the Dietary Aide. The [NAME] said the Dietary Aide is supposed to double-check the resident's meal plate against their meal ticket to ensure the diet order is correct before placing the meal plate on the tray.During an interview on 03/24/26 at 12:48 P.M., Dietary Aide #1 said he worked 6:00 A.M. to 2:30 P.M. on 03/04/26 and called out all residents' diet orders to the Cook. Dietary Aide #1 said the lunch meal was Chicken parmesan with spaghetti noodles. Dietary Aide #1 said when he calls out a resident's diet order, the cook prepares the meal plate, hands it back to him, and he is supposed to then check that the meal on the plate matches the resident's meal ticket before placing it on the tray and into the food truck.Dietary Aide #1 said Resident #1 was on a ground diet and he did not realize he had made a mistake with his/her meal plate. Dietary Aide #1 said he must have read the wrong resident's diet order to the cook for a regular diet and placed the plate with the regular diet on Resident #1's tray. Dietary Aide #1 said he did not check if Resident #1's meal ticket matched the meal on the plate before he covered the plate and placed it on his/her tray.During an interview on 03/24/26 at 4:18 P.M., the Food Service Director (FSD) said a Dietary Aide calls out all resident's diet orders, any restrictions, allergies, and preferences from their meal tickets to the Cook, the [NAME] prepares the meal plate according to what the Dietary Aide calls out and hands the plate to the Dietary Aide. The FSD said the Dietary Aide is supposed to check the meal on the plate to the resident's meal ticket to make sure that the meal is correct, then covers the plate, places it on the tray in the food truck. The FSD said Resident #1 had a house ground texture diet order and on 03/04/26 he/she was served a regular texture diet order which was a whole piece of chicken that was not grounded up. The FSD said Dietary Aide #1 told her that he could not remember if he had put the wrong meal on Resident #1's tray and that he was unaware the wrong diet texture had been sent to the unit for Resident #1.The FSD said it is her expectation that the Dietary Aides follow the process for preparing all residents' meal trays and they are double checking the meal on the plate against the resident's meal tickets to make sure they receive the correct diet order.During an interview on 03/30/26 at 4:06 P.M., (which included review of her written statement), Nurse #3 said she worked the 6:00 A.M. to 2:30 P.M. shift on 03/04/26. Nurse #3 said around 12:15 P.M. she was sitting at the nurses' station across from the secondary dining room with Nurse #2 and Nurse #3 when she heard a resident (exact name unknown) say to Resident #1 are you choking? Nurse #3 said she looked at Resident #1, saw him/her doing the universal choking sign (person clutches one or both hands to their throat), she immediately ran into the dining room and asked Resident #1 are you choking?' and he/she nodded yes. Nurse #3 said she got behind Resident #1, performed the Heimlich Maneuver on him/her and a piece of chicken expelled from his/her mouth. Nurse #3 said she observed Resident #1's lunch tray which had chicken parmesan on it and the chicken had been cut up into pieces. Nurse #3 said she did not know what Resident #1's diet order was, so she looked it up and saw that he/she had an order for a ground diet but had been given a regular texture diet.During an interview on 03/25/26 at 2:56 P.M., the Director of Nursing (DON) said nurses were responsible for checking all residents' meal trays according to the resident's meal ticket to ensure they receive the correct meal and that it is her expectation that all nurses check residents' meal trays before being passed to them.During a telephone interview on 03/30/26 at 1:09 P.M., the Former Administrator said on 03/04/26 Nurse #3 informed him that Resident #1 (whose diet order was for ground diet, had been served regular consistency diet) had choked on his/her lunch meal, that she (Nurse #3) performed the Heimlich Maneuver on him/her, he/she had expelled some food and he started an investigation right away. The Former Administrator said the FSD told him that on 03/04/26 the incorrect meal texture was prepared for Resident #1 and that he/she should have received his/her meal according to his/her diet order (ground diet).On 03/25/26, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction with an effective date of 03/06/26, which addressed the area(s) of concern as evidenced by:A. On 03/04/26, Resident #1 was assessed by the nurse, the physician was notified, and a new order was obtained for a chest X-ray. Resident #1 returned to his/her baseline after the incident and had no further complaints.B. On 03/04/36 Resident #1 was evaluated by the Speech Language Pathologist and seen six days during 03/04/36 through 03/13/26 with recommendations to continue ground diet and no waffles or pasta.C. On 03/05/26, the Unit Managers conducted a house wide audit on all units: to ensure all residents' meal trays were checked for accuracy according to their diet order on their meal tickets prior to meal service.D. On 03/04/26, the Staff Development Coordinator initiated and provided education to all Licensed Nursing Staff on checking residents' meal trays for accuracy according to their meal ticket prior to meal service: all Licensed nurses are to check all meal trays to ensure the correct diet on the meal ticket matches the meal.E. On 03/05/26, the Food Service Director provided education to all Dietary staff on checking meal trays for meal accuracy: all resident meal trays must be checked for accuracy during meal service to ensure that each meal plated is accurate according to each resident's diet orders/texture on their meal tickets.F. On 03/05/26, the Dietary Department Management started daily audits on all residents' meal trays for accuracy according to their meal tickets.G. The Nursing Department Staff will continue to conduct audits on resident's meal trays for accuracy according to their diet orders on the meal tickets daily for seven days, then weekly for four weeks, then monthly for a minimum of two QAPI cycles.H. The Dietary Department Management will continue to conduct audits on residents' diet orders on the meal tickets are accurate to the meal tray being served daily for seven days, then weekly for four weeks, then monthly for a minimum of two QAPI cycles.I. The results of the audits will be presented and reviewed at the quarterly QAPI meeting for a minimum of two quarters or until substantial compliance is achieved.J. The Director of Nursing, Food Service Director, and/or designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on the assistance of staff for transfers, the Facility failed to ensure his/her environment was free from potential hazards as is possible when on 09/22/25 sometime around 10:00 P., as Resident #1 was being transferred into bed with the assistance of two staff members, his/her left lower extremity scraped up against an exposed piece of metal on the bed frame joint and he/she sustained a 10-centimeter (cm) laceration to his/her left lower extremity that required 10 sutures to close. Findings include:Review of the Facility Policy titled, Equipment Management Plan, dated as reviewed January 2025, indicated the following:-all equipment, including beds, is functional and safe for use by all residents and is maintained appropriately by qualified individuals;-equipment is checked for functionality and safety in order to foster a safe environment;-the Facility will conduct yearly inspections or sooner as per manufacturer recommendations of all medical equipment and all equipment will be inspected and maintained in safe reliable operation.Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 09/23/25, indicated that on 9/22/25 around 10:00 P.M., Resident #1 sustained a laceration to his/her left outer calf during a transfer into bed, was transferred to the Hospital Emergency Department (ED) and required 10 sutures to repair the laceration. The Report indicated that upon sitting down onto the bed, Resident #1's left leg scraped up against the exposed metal bed frame joint, and he/she sustained a laceration to his/her left lower outer calf. The Report indicated that as a corrective measure, Resident #1's bed frame joints were covered with (protective plastic) end caps.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she presented to the Hospital ED with a laceration of the left leg. The Summary indicated that Resident #1 sustained a 10 cm semilunar (involving the skin and underlying tissue and cause significant bleeding) laceration along the lateral aspect of his/her left leg, had a small amount of arterial bleeding and required 10 sutures to repair the laceration.Resident #1 was admitted to the Facility in August 2025, diagnoses included acute kidney failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, anemia and atrial fibrillation.Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 09/19/25, indicated Resident #1 was moderately cognitively impaired and was dependent on staff for transfers.During an interview on 11/12/ 25 at 2:30 P.M., (which also included review of her written witness statement, dated 9/22/25) Nurse #1 said that on 9/22/25 she was in another resident's room when a Certified Nurse Aide (CNA) (exact name unknown) entered the room and asked her to come see Resident #1. Nurse #1 said that when she entered Resident #1's room, he/she was lying sideways in the bed, and he/she had a large wide-open laceration to his/her left leg that was actively bleeding.Nurse #1 said that the laceration happened during Resident #1's transfer by the CNAs from the wheelchair to bed. Nurse #1 said that Resident #1's left leg got caught on a piece of exposed metal on the bed frame and that she saw blood and fragments of skin on the piece of exposed metal on the bed frame. Nurse #1 said that she put a pressure dressing on the laceration, called 911 (Emergency Medical Services) and Resident #1 was transferred to the Hospital ED for treatment of his/her laceration. Nurse #1 said that Resident #1 returned from the Hospital ED with 10 sutures to his/her left leg.During an interview on 11/12/25 at 2:50 P.M., (which also included review of her written witness statement, dated 9/22/25) CNA #1 said that CNA #2 asked her to help she transfer Resident #1 into bed on 9/22/25 sometime around 10:00 P.M. CNA #1 said that both of them stood Resident #1 to pivot him/her into bed. CNA #1said Resident #1's left leg caught the bed frame and that a piece of exposed metal from the bed frame caused him/her to get a laceration to his/her left leg. CNA #1 said that Resident #1 was sitting at the edge of the bed with his/her legs hanging down and said that there was a lot of blood coming from the laceration. CNA #1 said they physically lifted Resident #1 into bed and notified the nurse. During a telephone interview on 11/17/25 at 9:35 A.M., (which also included review of her written witness statement, dated 9/22/25) CNA #2 said that on 9/22/25 around 10:00 P.M., she asked CNA #1 to help her transfer Resident #1 into bed. CNA #2 said that they both stood Resident #1 up to pivot him/her into bed. CNA #2 said Resident #1 began letting go, his/her knees began to buckle so they grabbed onto the waist band of his/her pants and lifted him/her into bed. CNA #2 said that during the transfer, Resident #1's left leg bumped into the bed frame and a piece of exposed metal caused him/her to get a laceration. CNA #2 said that there was a lot of blood from the laceration and the piece of metal on the bed frame had blood on it as well. CNA #2 said that she notified the nurse of the incident. During an interview on 11/12/25 at 11:00 A.M., the Director of Maintenance said that he was notified by the Administrator that Resident #1 was involved in an incident involving exposed metal on his/her bed frame and that he/she sustained a laceration from it. The Director of Maintenance said that when he inspected Resident #1's bed, he saw a piece of metal from the bed frame was exposed without the black (protective) plastic cap on it. The Director of Maintenance said that the beds were [AGE] years old and that some of the plastic caps have come off that piece of metal from the bed frame. The Director of Maintenance said that Resident #1 caught his/her leg on the exposed metal of the bed frame, sustained a laceration from the exposed piece of metal, and said the black plastic cap should have been in place on the piece of metal to protect it.During an interview on 11/12/25 at 3:30 P.M., the Director of Nurses (DON) said that two CNA's transferred Resident #1 into bed, and his/her left leg scraped against an exposed piece of metal from the bed frame, and he/she sustained a laceration from it. The DON said that the exposed metal did not have a plastic protective cap on it and said that the exposed metal caused the laceration. During an interview on 11/12/25 at 3:50 P.M., the Administrator said that he was notified that Resident #1 sustained a laceration to his/her left leg from an exposed piece of metal on his/her bed frame during a transfer into bed. The Administrator said that during his investigation, he saw dried up blood on the bed frame and on the piece of exposed metal from the bed frame. The Administrator said that the piece of metal on the bed frame did not have the protective black plastic cap on it. The Administrator said that the exposed piece of metal caused the laceration to Resident #1's left leg.The Administrator and the DON also said as part of the facility's investigation, they determined that neither CNA used a gait belt (safety device used to assist individuals with mobility challenges during transfers) during the transfer to maintain the resident's safety (per facility policy).On 11/12/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 09/25/25, which addressed the area(s) of concern as evidenced by:A. On 09/22/25, Nursing immediately assessed Resident #1's injuries, a pressure dressing was applied to the left leg laceration, 911 was called and he/she was transferred to the Hospital Emergency Department for evaluation.B. 09/23/25 through 09/26/25, the Staff Development Coordinator (SDC) provided re-education and re-trained all Licensed staff and CNAs on proper transfer mechanics, which included use of gait belts.C. On 09/23/25, the Director of Maintenance completed a whole house audit of all of the beds in the Facility to identify any missing caps on the bed frame to ensure that there is no exposed metal, identified any sharp edges or defective parts on the bed frame and joints. Caps were ordered and beds with missing caps, were identified and caps were placed.D. On 09/24/25, A Quality Assurance Performance Improvement (QAPI) Action Plan was developed on Resident Safety - Laceration During Transfer, Transfer Mechanics and Potential Environmental Hazard - Exposed Bed Frame Joint.E. On 09/25/25, the Unit Managers conducted daily visual observation audits on their units to ensure staff are using gait belts during transfers and that staff are transferring the residents with the appropriate number of staff assistance.F. Unit Managers will conduct Resident Transfer Observation Audits daily for seven days, then weekly for four weeks and then monthly for three months.G. The Director of Maintenance will audit resident beds for exposed metal, sharp edges or defective parts monthly for three months.H. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for three months or until compliance is achieved.I. The Administrator and the Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on the assistance of staff for transfers, the Facility failed to ensure staff provided care consistent with professional standards of practice, when on 09/22/25 at 9:55 P.M., Resident #1 was transferred into bed with the assistance of two staff members, without the use of a gait belt (safety device used to assist individuals with mobility challenges during transfers) per facility policy, his/her knees buckled during the transfer, and staff had to grab Resident #1 by the waist band of his/her pants to try to prevent him/her from falling. Findings include:Review of the Facility Policy titled, Gait Belt Policy and Procedure, dated as revised March 2024, indicated that a gait belt should be used for all residents during functional transfers when physically assisted with transfers to provide a safe environment for all residents and staff.Review of the Facility Policy titled, Safe Lifting and Movement of Residents, dated as revised July 2017, indicated that the facility used appropriate techniques and devised to lift and move residents in order to protect the safety and well-being of staff and residents and to promote quality care. The Policy indicated that staff responsible for direct resident care will be trained in the use of gait belts. Resident #1 was admitted to the Facility in August 2025, diagnoses included acute kidney failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, anemia and atrial fibrillation.Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 09/19/25, indicated Resident #1 was moderately cognitively impaired and was dependent on staff for transfers.Review of the Facility's Internal Investigation Report, dated 9/23/25, indicated that on 9/22/25, Resident #1 sustained a laceration during a 2-person transfer from wheelchair to bed. The Report indicated that a gait belt was not used during the transfer (per facility policy) and that nursing staff were educated on proper transfer techniques.During an interview on 11/12/ 25 at 2:30 P.M., (which also included review of her written witness statement, dated 9/22/25) Nurse #1 said that on 9/22/25 she was in another resident's room when a Certified Nurse Aide (CNA) (exact name unknown) entered the room and asked her to come see Resident #1. Nurse #1 said that when she entered Resident #1's room, he/she was lying sideways in the bed with a laceration to his/her left leg. Nurse #1 said that the laceration happened during a transfer from wheelchair to bed and said she was unsure if the CNA's used a gait belt during the transfer. Nurse #1 said that it is the Facility's policy for staff to use a gait belt during all resident transfers. During an interview on 11/12/25 at 2:50 P.M., (which also included review of her written witness statement, dated 9/22/25) CNA #1 said CNA #2 asked her to help transfer Resident #1 into bed on 9/22/25 sometime around 10:00 P.M. CNA #1 said that both of them stood him/her up from the wheelchair to pivot Resident #1 into bed. CNA #1 said that she was aware that it was the Facility's policy to use a gait belt but said they did not use a gait belt during Resident #1's transfer. CNA #2 said Resident #1's left leg caught the bed frame and that a piece of exposed metal from the bed frame caused him/her to get a laceration on his/her left leg. During a telephone interview on 11/17/25 at 9:35 A.M., (which also included review of her written witness statement, dated 9/22/25) CNA #2 said that on 9/22/25, Resident #1 was on her assignment and that around 10:00 P.M., she asked CNA #1 to help her transfer Resident #1 into bed. CNA #2 said that they both stood him/her up from the wheelchair to pivot Resident #1 into the bed, and that they did not use a gait belt during the transfer. CNA #2 said during the transfer, Resident #1 began letting go and his/her knees began to buckle so they grabbed onto the waist band of his/her pants and lifted him/her into bed. CNA #2 said that during the transfer, Resident #1's left leg bumped into the bed frame and a piece of metal was exposed caused him/her to get a laceration. CNA #2 said that she was aware that it was the Facility's policy to use a gait belt during all resident transfers and said that they should have used a gait belt during the transfer.Review of Certified Nurse Aide (CNA) #2's personnel file indicated the following:-On 2/13/24, CNA #2 signed a Gait Belt Policy & Procedure acknowledgement which indicated that a gait belt should be used for all residents during physically assisted functional transfers to provide a safe environment for all residents and staff. The Policy further indicated that noncompliance with use of gait belt will result in disciplinary action.-On 8/16/24, CNA #2 signed an Orientation Form acknowledgement which indicated that she was aware of the Facility's Gait Belt Policy and Procedure.-On 4/13/25, CNA #2 signed an Annual Competency Review which indicated that she demonstrated competence with the Facility's Gait Belt Policy and Procedure.Review of CNA #2's Text Message, sent to the Administrator, undated, indicated that no gait belt was used [on 9/22/25] during the transfer with Resident #1.During an interview on 11/12/25 at 3:30 P.M., the Director of Nurses (DON) said that two CNA's transferred Resident #1 into bed, said his/her left leg scraped against an exposed piece of metal from the bed frame and said he/she sustained a laceration from the exposed metal of the bed frame. The DON said that she did not believe that the two CNAs used a gait belt during the transfer at the time of the incident. The DON said that it was the Facility's policy to use gait belts during resident transfers and said it was her expectation that staff use gait belts. During an interview on 11/12/25 at 3:50 P.M., the Administrator said that he was notified that Resident #1 sustained a laceration to his/her left leg from an exposed piece of metal from the bed frame during a transfer into bed. The Administrator said that during the transfer, neither of the CNA's used a gait belt, and that it was Facility policy to use gait belts during all resident transfers. The Administrator said that both CNAs did not follow the Facility's policy. On 11/12/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 09/25/25, which addressed the area(s) of concern as evidenced by:A. On 09/22/25, Nursing immediately assessed Resident #1's injuries, a pressure dressing was applied to the left leg laceration, 911 was called and he/she was transferred to the Hospital Emergency Department for evaluation.B. 09/23/25 through 09/26/25, the Staff Development Coordinator (SDC) provided re-education and re-trained all Licensed staff and CNA's on proper transfer mechanics, which included use of gait belts.C. On 09/23/25, the Director of Maintenance completed a whole house audit of all of the beds in the Facility to identify any missing caps on the bed frame to ensure that there is no exposed metal, identified any sharp edges or defective parts on the bed frame and joints. Caps were ordered and beds with missing caps, were identified and caps were placed.D. On 09/24/25, A Quality Assurance Performance Improvement (QAPI) Action Plan was developed on Resident Safety - Laceration During Transfer, Transfer Mechanics and Potential Environmental Hazard - Exposed Bed Frame Joint.E. On 09/25/25, the Unit Managers conducted daily visual observation audits on their units to ensure staff are using gait belts during transfers and that staff are transferring the residents with the appropriate number of staff assistance.F. Unit Managers will conduct Resident Transfer Observation Audits daily for seven days, then weekly for four weeks and then monthly for three months.G. The Director of Maintenance will audit resident beds for exposed metal, sharp edges or defective parts monthly for three months.H. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for three months or until compliance is achieved.I. The Administrator and the Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in condition on 8/08/25, the Facility failed to ensure the Provider was notified.Findings include:Review of the Facility's Policy titled, Change in a Resident's Condition or Status, dated as revised, May 2017, indicated the following:-the facility shall promptly notify the resident's physician and representative of changes in the resident's medical, mental condition or status;- the nurse will notify the resident's physician when there has been a significant change in the resident's physical, emotional or mental condition;-the nurse will notify the resident's physician when there has been a need to alter the resident's medical treatment significantly;-unless otherwise instructed, the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status;Resident #1 was admitted to the Facility in April 2024, diagnoses included shock, sepsis, cellulitis, chronic kidney disease stage 3, acute on chronic respiratory failure with hypoxia, inflammatory liver disease, and chronic pulmonary edema.Review of an Interdisciplinary Progress Note, (written by Nurse #2) and Resident #1's Medication Administration Record (MAR), dated 8/08/25, (signed off by Nurse #2), indicated that Resident #1's Oxygen Saturation (how much oxygen is being transported through the body) level was 84% (severe hypoxemia - dangerously low oxygen level) (Normal Range: 95% - 100%). Review of an Interdisciplinary Progress Note, (written by Nurse #2), dated 8/10/25 at 5:00 A.M., indicated that Resident #1 has been using oxygen consistently and may need to be on continuous oxygen, currently utilizing oxygen at 4 Liters via nasal cannula, noted in MD binder.Review of an Interdisciplinary Progress Note, (written by Nurse #2), dated 8/10/25 at 8:47 A.M., (written by Nurse #2), indicated that Resident #1 appears to be increasingly more anxious with intermittent moments of confused statements that make little to no sense, findings noted in MD binder for review when provider is reportedly in house at start of week.During a telephone interview on 09/04/25 at 12:26 P.M., Nurse #2 said that Resident #1 was on oxygen as needed and when she checked his/her oxygen saturation, the level was 84 % (with oxygen). Nurse #2 said that it was a very low oxygen level and she increased Resident #1's oxygen Liter flow to 4 L (Liters per minute). Nurse #2 said that Resident #1 required continuous oxygen and required a higher Liter flow to maintain normal oxygen saturation levels and said this was new for him/her. Nurse #2 said that she did not notify the Physician or the Nurse Practitioner and said she left a note for the Physician in the Physician's folder about the change in condition.During a telephone interview on 9/04/25 at 12:00 P.M., the Physician said that she was not notified that Resident #1 was hypoxic and had an oxygen saturation level of 84% (with oxygen) and was not notified that he/she required a higher level of Liter flow to maintain normal oxygen saturation levels. The Physician said that Resident #1 was on oxygen as needed to maintain normal oxygen saturation levels. The Physician said that it was her expectation that nurses would notify her if a resident was hypoxic, had a low oxygen saturation level and/or required a higher Liter flow to maintain normal oxygen saturation level. The Physician said that is a significant change in condition and she expected to be notified immediately.During an interview on 9/04/25 at 1:45 P.M., the Unit Manager said that Resident #1 was on oxygen as needed and said she was unaware that Resident #1 required the use of continuous oxygen. The Unit Manager said that she was unaware that Resident #1 had a low oxygen saturation level and required a higher oxygen Liter flow to maintain normal oxygen levels. The Unit Manager said that she expected nurses to notify the Physician or NP of a low oxygen saturation level. The Unit Manager said that a low oxygen saturation level is a change in condition and should be reported to the Provider so that it can be addressed immediately.During a telephone interview on 9/04/25 at 2:04 P.M., Nurse Practitioner (NP) #1 said that she was not notified that Resident #1 had an oxygen saturation level of 84% and was not notified that he/she required a higher level of Liter flow to maintain normal oxygen saturation levels. The NP said that it was her expectation that nurses would notify her if a resident had a low oxygen saturation level and/or required a higher Liter flow to maintain normal oxygen saturation level. The NP said that is considered a significant change in condition and she should be immediately notified. Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #2 notified his/her NP or Physician of Resident #1's low oxygen saturation level and requiring a higher Liter flow of oxygen.During an interview on 9/04/25 at 2:25 P.M., the Director of Nursing (DON) said she was not notified that Resident #1 had an oxygen saturation level of 84% and required a higher liter flow of oxygen to maintain normal oxygen saturation levels. The DON said that it was her expectation that nurses notify the Provider immediately of a low oxygen saturation level as well as if a resident required a higher Liter flow of oxygen to maintain normal oxygen levels. The DON said that a low oxygen saturation level and requiring a higher Liter flow of oxygen is considered a change in condition and requires immediate notification to the Provider.

Based on observation, interview, and document review, the facility failed to 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 implemented appropriate use of personal protective equipment (PPE) for residents placed on Isolation Precautions and ensure staff implemented appropriate use of source control PPE while on the units in the facility during a COVID-19, Influenza (FLU) and Respiratory Syncytial Virus (RSV) outbreak to help prevent the further spread of illness on three of three units observed. Findings include: Review of the facility's policy titled Infection Prevention Control, dated as reviewed 10/2024, indicated but was not limited to the following: -Standard and transmission-based precautions to be followed to prevent the spread of infections Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated as revised September 2022, indicated but was not limited to the following: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. -The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE. -When transmission-based precautions are in effect, non-critical care equipment items will be dedicated to a single resident -If re-use of items is necessary, then the items will be clean and disinfected according to current guidelines before use with another resident Review of the facility's policy titled Coronavirus COVID-19, dated as revised 1/2014, indicated but was not limited to the following: -Use of Personal Protective Equipment (PPE) -Full PPE, including N-95 respirator, eye protection, gloves, and gown should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19 -If reusable goggles or face shields are used the facility must ensure appropriate cleaning and disinfection between uses according to manufacturer's instructions. -Clean and disinfect reusable equipment prior to removing from resident's room Upon entrance to the facility on [DATE] at 7:30 A.M., the Director of Nursing (DON) said the facility was currently undergoing an outbreak of COVID-19, FLU, and RSV. She said the facility is requiring all staff and visitors to utilize face masks and face shields or goggles while in the facility. Review of the most recent outbreak documentation provided by the DON on 2/12/25 at 8:44 A.M., indicated the facility had five residents currently positive for RSV and five residents currently positive for the FLU on North 1 unit. The facility had 10 residents currently positive for the FLU on North 2 unit. The South 2 unit currently had two residents positive for the FLU and three residents positive for COVID-19. On 2/12/25 at 9:34 A.M., the surveyor observed a table next to the elevator on the basement floor with goggles and face shields placed in an open plastic bin, and a box of face masks. Above the table a sign was posted which read - Face masks and goggles or face shields required on all units. On 2/12/25 at 9:36 A.M., the surveyor observed a staff member pushing a cart down the hallway on the North 1 unit with only a face mask in place, no goggles or face shield was worn. On 2/12/25 at 9:42 A.M., the surveyor observed a table next to the elevator on the second floor with goggles and face shields placed in an open plastic bin, and a box of face masks located next to it. Above the table a sign was posted which read - Face masks and goggles or face shields required on all units. On 2/12/25 at 9:45 A.M., the surveyor observed a hospice staff member at the nursing station on the North 2 unit wearing only a face mask, no goggles or face shield was worn. On 2/12/25 at 9:46 A.M., the surveyor observed a maintenance staff member repairing a medication cart, located on the North 2 unit, in the hallway, wearing only a face mask, no goggles or face shield was worn. During an interview on 2/12/25 at 9:49 A.M., Unit Manager (UM) #1 said everyone is required to wear a facemask and eye protection while in the facility because of the current outbreak. She said if a resident is positive for the FLU, COVID-19, or RSV, there is a sign outside of the door that says isolation precautions. UM#1 said all staff must wear a gown, gloves, eye protection and an N-95 mask (a filter mask that fits over the nose and mouth to protect against airborne particles) prior to entering the room. She said the staff does not need to change or clean eye protection when they exit an isolation room. On 2/12/25 at 9:50 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter a resident's room on the North 2 unit, wearing gloves, surgical face mask and goggles. The room had a sign posted in the doorway that read general PPE precaution facility with COVID cases in the last 14 days, indicating staff were required to clean hands when entering and exiting, wear a gown, mask (N-95 for aerosol generating procedures), eye protection and gloves prior to entering the room. CNA #1 made the resident's bed, doffed (removed) her gloves and exited the room. The CNA did not perform hand hygiene after removing her gloves. The CNA did not don (put on) a gown prior to entering the room. A PPE holder was located on the front of the resident's door stocked with gowns, and an alcohol-based hand sanitizer pump (ABHS) was located on the wall outside of the room to complete hand hygiene. On 2/12/25 at 9:52 A.M., the surveyor observed CNA#1 approach the doorway to another resident's room on the North 2 unit, still did not perform hand hygiene, don an N-95 mask, gown, and gloves and entered the room. The N-95 face mask was applied with one strap placed around the back of her head, and the other was left dangling in front of her face, leaving the mask loose fitting. The room had an isolation contact/droplet precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, wear eye protection, a gown, an N-95 mask, and gloves prior to entering the room. The surveyor observed CNA #1 transfer the resident from the bed to the chair and then CNA #1 returned to the PPE bin located on the door of the room. CNA #1 reached into the bin and grabbed some N-95 masks. CNA #1 was still wearing the gloves she used to transfer the resident into the chair. She then dropped two clean N-95 masks on the ground, picked up the N-95 masks from the ground and placed them back in the clean PPE holder and then returned to assist the resident. On 2/12/25 at 10:01 A.M., the surveyor observed CNA #1 doff her gown and gloves and exit the resident's room. She walked down the hallway and doffed her N-95 mask at the nursing station, performed hand hygiene and put on a surgical face mask. CNA #1 did not change or clean her goggles after exiting the isolation precaution room. During an interview on 2/12/25 at 10:04 A.M., CNA #1 and the surveyor reviewed the general PPE precaution sign together that was posted outside of the first resident's room she had entered. She said the sign is placed on all the resident doors who are not on precautions. She said it is because the facility has COVID and FLU in the building. CNA #1 said she is aware the sign says to wear a gown, but she does not have to wear a gown when entering the room. CNA said she thought she cleaned her hands when she exited the room, and before she entered another resident's room, but must have forgotten. She said when she enters a room that has an isolation precaution sign, she must wear an N-95, gown, gloves and goggles. She said she does not have to change or clean her goggles upon entering or exiting the room. During an observation with an interview on 2/12/25 at 10:20 A.M., the surveyor observed CNA #3 enter a resident's room on the South 2 unit, wearing a surgical face mask, and goggles. The room had an isolation contact/droplet precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, wear eye protection, a gown, an N-95 facemask, and gloves prior to entering the room. CNA #3 spoke with the resident and then exited the room. CNA #3 said she is only required to wear an N-95, gown and gloves when she is providing care to the residents, and since she is only speaking with them it is not required. CNA #3 said when a resident is on isolation precautions she does not have to change or clean her eye protection when exiting the room. After speaking with the surveyor, CNA #3 performed hand hygiene, donned a gown and gloves and re-entered the room. CNA #3 did not don an N-95 mask prior to entering the room. A PPE holder was located on the front of the resident's door stocked with N-95 masks. During an interview on 2/12/25 at 10:29 A.M., UM #2 said the PPE for precautions on the unit are for all staff and visitors to wear eye protection and a face mask while on the units. She said rooms with a sign posted saying isolation precautions require use of gowns, N-95 masks, gloves and eye protection to be worn upon entering. She said the general precaution sign that is placed outside of some resident rooms is confusing. She said PPE is not required to enter those rooms, and she is not sure why the sign states it is required. UM #2 said she will check with the DON for clarification. During an observation with an interview on 2/12/25 at 10:36 A.M., the surveyor observed CNA #5 approaching a resident's room on the North 1 unit wearing a surgical face mask and eye shield. CNA #5 donned a gown and gloves and entered the room. CNA #5 did not perform hand hygiene prior to donning the gloves. The room had an isolation contact/droplet precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, wear eye protection, a gown, an N-95 facemask, and gloves prior to entering the room. CNA #5 them removed her gown and gloves and exited the room. CNA #5 did not perform hand hygiene, remove her surgical face mask, or clean her face shield. A PPE holder was located on the front of the resident's door stocked with N-95 masks and face shields. A hand sanitizer dispenser was located on the wall outside of the room to complete hand hygiene. CNA #5 and the surveyor reviewed the precaution sign located outside of the room together. CNA #5 said she should have cleaned her hands prior to entering and exiting the room. She said she was never told to change her face mask or clean her face shield when leaving an isolation room. She said she should have worn an N-95 mask, On 2/12/25 at 10:37 A.M., the surveyor observed Housekeeper #1 in a resident's room on the North 1 unit, wearing gloves, surgical face mask and goggles. The room had an isolation contact/droplet precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, wear eye protection, a gown, an N-95 facemask, and gloves prior to entering the room. The housekeeper had her cleaning cart placed in front of the doorway. She was dusting the bureau, then approached her cart, placed the dirty dusting rag used in the isolation room on top of folded dusting cloths on the cart, uncovered. She took the mop off the cart, returned to the room and mopped the resident's floor. She returned the mop to the cart, removed her gloves, and proceeded down the hall with her cart. Housekeeper #1 did not perform hand hygiene, change her surgical mask or change or clean her goggles. Housekeeper #1 did not clean the mop used in the isolation precaution room. Housekeeper #1 did not don a gown, or a N-95 mask prior to entering the room. A PPE holder was located on the front of the resident's door stocked with gowns, and N-95 masks for use. During an observation with an interview on 2/12/25 at 10:42 A.M., the surveyor observed Staff member #1 exit a resident's room wearing a surgical face mask and goggles. The room had an isolation contact/droplet precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, wear eye protection, a gown, an N-95 facemask, and gloves prior to entering the room. A PPE holder was located on the front of the resident's door stocked with gowns, and N-95 masks for use. Staff member #1 said she only has to put on an N-95 mask, gown, and gloves if she is providing direct care. She said it is not required to be worn just to enter the room. During an interview with the DON, Administrator, and Infection Preventionist (IP), on 2/12/25 at 12:42 P.M., the DON said the IP is in charge of the precautions and PPE use on the units. The IP said she is new to this role, and when the outbreak started someone else was handling it and provided the education to the staff. The IP said she expects the nursing staff to monitor the PPE use on the units. The Administrator said he put into place the general PPE use signs for any residents who do not require isolation precautions, and for all staff and visitors to wear eye protection and a face mask on the units to mitigate the spread of the current outbreak of COVID-19, FLU and RSV. The Administrator said the staff are expected to follow the guidelines on the signs posted outside of the rooms. The surveyor reviewed PPE breeches observed on all units with DON, Administrator, and IP. The Administrator said the facility needs to provide further education to ensure the staff use proper PPE and include all departments. The DON said her expectations are for the staff to follow the PPE signs placed outside of the resident doors at all times. She said full PPE with N-95 facemask was required prior to entering isolation precaution resident rooms. She said eye protection must be cleaned or discarded prior to exiting the room. The DON said when an N-95 is worn, it must be applied properly to obtain a tight seal. She said once PPE is touched or dropped on the floor, it is considered dirty and must be thrown away. The DON said hand hygiene must be completed prior to entering and exiting any resident's room.

Based on record review and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and failed to complete antibiotic usage audit tools (line listings), which are used to track, report and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of facility's policy titled Antibiotic Stewardship, last revised 12/2023, indicated but was not limited to the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. -All clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee -The IP will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed interventions, or not justified. -At the conclusion of the review, the provider will be notified of the review findings and recommendations, and his/her response will be documented. -All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered will include: Resident name, date symptoms appeared, name of antibiotic, start date, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome and adverse events. During an interview on 2/18/25 at 4:04 P.M., with the Director of Nursing (DON) , Infection Preventionist (IP) and the Administrator, the surveyor reviewed monthly antibiotic surveillance tracking records, dated November 2024, December 2024, and January 2025. The records were found to be incomplete as follows: The November 2024 tracking surveillance record, signed by the IP, dated 12/2/24, had missing documentation for 24 out of 27 residents. Nineteen residents had no documented culture date, site of infection, or results. Two residents had no documented culture date or site of infection. Three residents had no documented culture date, site of infection, results or infection status (i.e.: cleared/not cleared). All 27 residents were started on an antibiotic. The December 2024 tracking surveillance record, signed by the IP, dated 1/15/25, had missing documentation for 17 out of 26 residents. Sixteen residents had no documented culture date, site of infection, or results. One resident had no documented culture date, site of infection, results or infection status (i.e.: cleared/not cleared). All 26 residents were started on an antibiotic. The January 2025 tracking surveillance record, signed by the DON, undated, had missing documentation for 15 out of the 16 residents. Four residents had no documented culture date, site of infection or results. Six residents had no documented culture date, site of infection, results, infection status, or if the illness counted as an infection. Two residents had no documented symptoms, culture date, site of infection, results or if the illness counted as an infection. Two residents had no documented culture date, site of infection results, infection status or if the illness counted as an infection. One resident had no documented results or if the illness counted as an infection. All 16 residents were started on an antibiotic. After reviewing the surveillance tracking records, the Administrator said the facility uses McGeer criteria to determine if an illness is counted as an infection on the line listing. The IP said she just took this position a few weeks ago, is currently in training and has not completed any line listings yet. The DON said she has been tracking antibiotic use in the facility since the previous IP resigned back in January 2025. The DON said she reviews the resident progress notes daily and documents antibiotic use on the line listings. She then sends the completed line listings to the lab and they calculate the facility's antibiotic use. She said she has not reviewed any antibiotic use with McGeer criteria to determine if an illness meets the criteria for an infection, and the line listings are incomplete and incorrect. The DON said she does not review antibiotic justification for use or improvement of antibiotic prescribing practices with the providers per their antibiotic stewardship policy. The DON said she recently had an in-service with the nursing staff regarding the use of McGeer criteria and is in the process of training the new IP.

Based on interview and record review, the facility failed to provide the Pneumococcal immunization as requested/consented in a timely manner for one Resident (#56), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) information sheet titled Pneumococcal Timing Vaccine Timing for Adults, dated 9/12/24, indicated the following recommendation: -If a patient has had the Pneumococcal Conjugate Vaccine-13 (PCV-13 at type of pneumococcal vaccination) at any age and Pneumococcal Polysaccharide Vaccine-23 (PPSV23 a type of pneumococcal vaccination) at or after the age of 65 after 5 years PCV-20 or PCV-21 should be offered. -Together, with the patient, vaccine providers may choose to administer PCV-20 or PCV-21 to adults = [AGE] years old who have already received PCV-13 (but not PCV-15, PCV-20, or PCV-21) at any age and PPSV-23 at or after the age of [AGE] years old. Review of the facility's policy titled Facility Vaccine Procedure, dated as revised in 12/2024, indicated but was not limited to the following: -To offer each resident/employee the recommended immunizations against Pneumonia -Obtain informed consent from each resident/responsible party to receive recommended vaccines -The licensed nurse will distribute to the resident/responsible party, information annually regarding risks/benefits of receiving any vaccine and document in the resident record, receipt of educational information and appropriate informed consent/declination of vaccine -The licensed nurse will administer the designated vaccine to all residents who have signed the informed consent requesting to be vaccinated with the vaccine Resident #56 was admitted to the facility in February 2025. Review of Resident #56's Immunization Consent form indicated the Resident consented to the Pneumococcal vaccine. Review of the medical record failed to indicate Resident #56 had been administered the Pneumococcal vaccine. Review of the Resident's Immunization record indicated the following: -Pneumococcal PCV-13 vaccine administered 11/2/18, outside of the facility -Pneumococcal PPSV-23 vaccine administered 11/4/19, outside of the facility; given after the age of 65 During an interview on 2/13/25 at 1:53 P.M., Nurse #2 said when a resident admits to the facility the admitting nurse will review the vaccine options and obtain either consent or declination for the vaccines. The consents are then given to the Infection Preventionist (IP), and the IP obtains the physician's orders and administers the vaccine. She said the facility also holds vaccine clinics for the residents. She said the IP left the position a couple of weeks ago and is not sure who will be giving the vaccines now. During an interview on 2/13/25 at 2:31 P.M., the Administrator said the facility holds vaccine clinics quarterly. He said if a resident is admitted into the facility and wants a vaccine, that is not timed with the clinic, the IP will order it from the pharmacy they use at the facility and administer it. The Administrator said whoever administers the vaccine inputs the information into the Massachusetts Immunization Information System (MIIS) for a history of immunizations and updates the medical chart accordingly. During an interview on 2/18/25 at 3:39 P.M., with the Director of Nursing (DON), IP, and Administrator, the IP said she is new to this position and will be responsible for monitoring resident and staff vaccines the facility offers going forward. The DON said the floor nurses review the vaccine risks and benefits with the residents and have the consents signed upon admission. She said they would provide the IP with a copy of the consents or declinations and the IP would obtain the physician's orders, administer the vaccine and document the information in the resident's chart. The DON said Resident #56 qualified to receive the Pneumococcal PCV-20 vaccine and the IP should have followed through and administered the vaccine.

Based on interviews and record review, the facility failed to ensure its staff maintained accurate documentation for one Resident (#25), out of a total of 20 residents. Specifically, the facility failed to ensure February 2025, Medication Administration Records (MAR) accurately reflected blood sugar values and dosage of insulin administered according to physician's orders. Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revised 12/2020, indicated but was not limited to: -The Physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks) and adjust treatments based on these results. -Examples of blood glucose monitoring for various situations might include the following: -For the resident receiving insulin, monitor 3 to 4 times a day if on a sliding-scale insulin. -The Physician will authorize pertinent parameters for monitoring and reporting information related to blood sugar management. -The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. Resident #25 was admitted to the facility in January 2025 with diagnoses including diabetes mellitus. Review of Physician's Orders included but was not limited to: -Insulin Glargine 100 unit/1 millimeter (ML) solution (Insulin Glargine, Recombinant) give 20 units subcutaneous (SQ) every day at 9 AM -Lantus Solostar 100 units/1 ML solution (Insulin Glargine, Recombinant) give 10 units SQ every night at 8 PM -Insulin Lispro 100 units/1 ML solution (Insulin Lispro, Recombinant) Sliding Scale Injection Breakfast, Lunch, Supper for Capillary Blood Glucose (CBG) 100-150 Administer 2 Units, CBG 151-200 Administer 4 Units, CBG 201-250 Administer 6 Units, CBG 251-300 Administer 8 Units, CBG 301-350 Administer 10 Units, CBG 351-400 Administer 12 Units and notify MD. -Insulin Lispro 100 units/1 ML solution (Insulin Lispro, Recombinant) Sliding Scale Injection every night at 8 PM for CBG 100-150 Administer 2 Units, CBG 151-200 Administer 4 Units, CBG 201-250 Administer 6 Units, CBG 251-300 Administer 8 Units, CBG 301-350 Administer 10 Units, CBG 351-400 Administer 12 Units and notify MD. Review of the February 2025 MAR indicated the following blood sugars were not documented on 23 occasions as evidenced by several blank boxes corresponding to the dates and times blood sugars were to be obtained as follows: 2/1/25 17:30 2/2/25 07:30, 12:00, 17:30 2/3/25 07:30, 12:00, 17:30 2/4/25 07:30, 12:00, 17:30 2/5/25 20:00 2/6/25 20:00 2/7/25 20:00 2/8/25 20:00 2/9/25 20:00 2/10/25 20:00 2/11/25 20:00 2/12/25 20:00 2/13/25 20:00 2/14/25 20:00 2/15/25 20:00 2/16/25 20:00 2/17/25 20:00 Review of the February 2025 MAR indicated the following units of insulin were not documented on 24 occasions as evidenced by several blank boxes corresponding to the dates and times insulin were to be administered as follows: 2/1/25 17:30 2/2/25 07:30, 12:00, 17:30 2/3/25 07:30, 12:00, 17:30 2/4/25 07:30, 12:00, 17:30 2/5/25 20:00 2/6/25 20:00 2/7/25 20:00 2/8/25 20:00 2/9/25 20:00 2/10/25 20:00 2/11/25 20:00 2/12/25 20:00 2/13/25 20:00 2/14/25 20:00 2/15/25 20:00 2/16/25 20:00 2/17/25 20:00 2/18/25 20:00 During an interview on 2/18/25 at 12:32 P.M., the surveyor and Nurse #2 reviewed the physician's orders for insulin. Nurse #2 said the blood sugars and amount of insulin administered would be documented on the MAR. The surveyor and Nurse #2 reviewed the MAR and noted several missing entries. Nurse #2 reviewed the transcription of the insulin orders in the MAR. Nurse #2 said it appeared that the sliding scale order for breakfast, lunch and supper was clarified on 2/5/25 to include documenting the blood sugar and amount of insulin administered. Nurse #2 said the sliding scale for the 20:00 order was not completely entered. Nurse #2 said when the order was placed in the computer the supporting documents tab was not checked off to signify documenting blood sugar or amount of insulin administered. Nurse #2 said the Nurses would only be able to sign off their initials. During an interview on 2/19/25 at 1:03 P.M., the Director of Nurses (DON) noted there was no way to indicate what the blood sugar value was or how much insulin was administered. The DON said the expectation is nurses would document blood sugar values and amount of insulin administered on the MAR and follow up with the Physician if needed.

Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents. Specifically, the facility failed to discard food that was past the manufacturer's expiration and use by dates in one of three kitchenettes reviewed. Findings include: Review of the facility's policy titled Foods Brought in From an Outside Source Policy and Procedure, reviewed [DATE], indicated: - Foods or beverages brought in from the outside will be labeled with the residents' name and dated by staff with the date the item(s) are brought into the facility for storage. - Food or beverage in the original container that is past the manufacturer's expiration date will be discarded by facility staff. On [DATE] at 10:10 A.M, the surveyor, with the Food Service Director (FSD) present, reviewed the first floor, North Unit kitchenette and observed the following food items in the refrigerator which the FSD identified as being brought in from an outside source: -One resealable plastic bag of crab classic meat with an expiration date of [DATE] -One resealable plastic bag of salami with an expiration date of [DATE] -A bag of Halos oranges labeled use by [DATE]. During an interview on [DATE] at 10:30 A.M., the FSD said there should not be expired food in the residents' refrigerator. She said any food beyond the expiration date and the use by date should have been discarded by the dietary aides. The FSD said the oranges and the meat products, which were way beyond expiration, should have been discarded. The FSD said there should be a guide for foods brought in by resident families and friends attached to the kitchenette's refrigerator door, but the sign was not there. During an interview on [DATE] at 11:15 A.M., Diet Aide #1 said expired food should have been discarded from the refrigerator.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for seven Residents (#16, #38, #43, #48, #49, #52, and #84). Findings include: Review of the facility's policy titled MDS Policy and Procedure, dated as last revised ,d+[DATE], indicated but was not limited to the following: -It is the responsibility of the MDS Coordinator to ensure required assessments are completed and electronically submitted in accordance with submission requirements in the Resident Assessment Instrument (RAI) Manual. Review of Centers for Medicare and Medicaid Services (CMS) RAI Manual, Version 3.0, indicated assessments must be transmitted (submitted and accepted) in to CMS' Internet Quality Improvement and Evaluation System (iQIES) electronically no later than 14 calendar days after the MDS completion date. 1. Resident #16 was admitted to the facility in [DATE]. a. Review of the medical record indicated he/she was admitted to hospice services on [DATE]. Review of the significant change MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. b. Review of the medical record indicated he/she expired in the facility in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by MDS Nurse #1, a Licensed Practical Nurse (LPN) on [DATE] and failed to indicate the RN Assessment Coordinator had signed the MDS. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 2. Resident #38 was admitted to the facility in [DATE]. Review of the medical record indicated he/she was discharged to the community in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 3. Resident #43 was admitted to the facility in [DATE]. Review of the medical record indicated he/she expired in the facility in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by MDS Nurse #1, an LPN on [DATE] and failed to indicate the RN Assessment Coordinator had signed the MDS. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 4. Resident #48 was admitted to the facility in [DATE]. Review of the medical record indicated he/she was discharged to the community in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 5. Resident #49 was admitted to the facility in [DATE]. Review of the medical record indicated he/she was discharged to the community in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 6. Resident #52 was admitted to the facility in [DATE]. Review of the medical record indicated he/she was discharged to the community in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. 7. Resident #84 was admitted to the facility in [DATE]. Review of the medical record indicated he/she was discharged to the community in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by the RN Assessment Coordinator on [DATE]. Review of the iQIES submission data failed to indicate the MDS was transmitted and accepted. During an interview on [DATE] at 12:01P.M., MDS Nurse #1 said she was an LPN and completes the MDS assessments, then the RN MDS Coordinator signs off, and they are submitted to iQIES. She said an MDS needs to be done for a significant change, a death, and a discharge, and all would need to be submitted into iQIES within 14 days. She said the MDS assessments for Residents #16, #38, #43, #48, #49, #52, and #84, were not transmitted, were late, and would have to be submitted into iQIES. During an interview on [DATE] at 12:01 P.M., the RN MDS Coordinator/MDS Nurse #2 said she was not the RN MDS Coordinator at the time these MDS assessments should have been submitted. Additionally, she said they should have been submitted into iQIES within 14 days of completion and were all late.

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was signed off by the Registered Nurse (RN) MDS Coordinator as completed for two Residents (#16 and #43) per the Resident Assessment Instrument (RAI) guidelines. Findings include: Review of the facility's policy titled MDS Policy and Procedure, dated as last revised ,d+[DATE], indicated but was not limited to the following: -It is the responsibility of the MDS Coordinator to ensure required assessments are completed and electronically submitted in accordance with submission requirements in the RAI Manual. Review of Centers for Medicare and Medicaid Services (CMS) RAI Manual, Version 3.0, indicated an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility and is responsible for coordinating and certifying completion of the resident assessment. 1. Resident #16 was admitted to the facility in [DATE]. Review of the medical record indicated he/she expired in the facility in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by MDS Nurse #1, a Licensed Practical Nurse (LPN) on [DATE], and failed to indicate the RN Coordinator had signed the MDS. 2. Resident #43 was admitted to the facility in [DATE]. Review of the medical record indicated he/she expired in the facility in [DATE]. Review of the Discharge MDS assessment, dated [DATE], indicated it was completed and signed by MDS Nurse #1, an LPN on [DATE], and failed to indicate the RN Coordinator had signed the MDS. During an interview on [DATE] at 12:01P.M., MDS Nurse #1 said she was an LPN and completes the MDS assessments, then the RN MDS Coordinator signs off, and they are submitted to iQIES. She said the MDS assessment for Residents #16 and #43, were not signed by the RN Coordinator and should have been. During an interview on [DATE] at 12:01 P.M., the RN MDS Coordinator/MDS Nurse #2 said she was not the RN MDS Coordinator at the time of these MDS assessments, but all MDS assessments must be signed as complete by an RN. During an interview on [DATE] at 4:15 P.M., MDS Nurse #1 said the previous RN MDS Coordinator used to sign off the RN Attestation for all MDS assessments and these death MDS assessments should have been signed and were not.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had a diagnosis of Dysphagia (difficulty swallowing), required an altered textured diet and continual supervision (staff member to stay with resident during entire task) during meals, the Facility failed to ensure that he/she was provided with the necessary level of staff supervision during meals in an effort to maintain his/her safety to prevent an incident of choking. On 12/21/24, Resident #1 was served his/her lunch time meal tray in his/her room, however the staff member did not stay to provide supervision while he/she ate. Resident #1 was also served food items that were inconsistent with his/her diet orders. Resident #1 choked on the food and required the Heimlich Maneuver. Findings Include: Review of the Facility's Policy tilted Assisting the Resident with In-Room Meals, dated as revised December 2013, indicated the following: -the purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms -check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: -food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident -if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Resident #1 was admitted to the Facility in October 2019, diagnoses included senile degeneration of the brain (neurological disorder that causes a decline in cognitive function), dysphagia (difficulty swallowing), gastro-esophageal reflux disease, feeding difficulties, hyperlipidemia (high cholesterol), and anxiety. Review Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she had severe cognitive impairment. Review of Resident #1's Self Care Deficit Care Plan related to ADLs, renewed and reviewed with his/her November 2024 MDS, indicated that he/she required continual supervision with meals. Review of Resident #1's Physician's Orders, dated December 2024, indicated he/she required a House regular, with foods to be chopped diet. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/21/24, at approximately 12:00 P.M. a Certified Nurse Aide (CNA) observed Resident #1 to be choking on his/her food, and he/she required the Heimlich Maneuver to dislodge the food. The Report indicated that Resident #1's lunch meal was not prepared by the cook according to his/her diet, nursing staff did not check his/her meal tray for accuracy according to his/her meal ticket, he/she was served the incorrect meal texture, and he/she did not receive assistance (staff supervision) with his/her meal. Review of Resident #1's Lunch meal ticket, dated 12/21/24, indicated that he/she required a House Chopped diet and noted under his/her preferences was that all meals were to be chopped. Review of Resident #1's Nurse Progress Note, dated 12/23/24 as a late entry for 12/21/24, (written by Nurse #1), indicated that Resident #1 was found by a Certified Nurse Aide (CNA) in his/her room choking while he/she was eating and Nurse #1 performed the Heimlich Maneuver, expelling a small piece of meatball from Resident #1's mouth. The Note indicated Resident #1's vital signs were taken, he/she was encouraged to cough and clear his/her throat with good effect, and he/she was then allowed to rest. During an interview on 01/15/25 at 10:04 A.M., (which included review of her written employee statement), Certified Nurse Aide (CNA) #3 said on 12/21/24 she was walking towards Resident #1's room, heard him/her struggling to cough and went into his/her room. CNA #3 said Resident #1 was sitting on the side of the bed, his/her meal tray was in front of him/her, his/her face was red and turning purple in color and she realized that he/she was choking. CNA #3 said she yelled out help he/she is choking and CNA #2 came into the room while CNA #1 went to get Nurse #1. CNA #3 said that CNA #2 got behind Resident #1, she (CNA #2) started the Heimlich Maneuver as Nurse #1 entered the room, and CNA #3 said Nurse #1 and CNA #2 stood Resident #1 up, Nurse #1 took over doing the Heimlich Maneuver on him/her and a piece of a meatball came up into his/her mouth. CNA #3 said when she entered Resident #1's room, there were no staff member in the room supervising him/her while he/she was eating. During an interview on 01/14/25 at 2:45 P.M., (which included review of her written employee statement), CNA #2 said on 12/21/24 she heard CNA #3 yell out Nurse help, Resident #1 is choking. CNA #2 said she ran to Resident #1's room and saw that he/she was in distress, his/her face was red, and he/she was not speaking. CNA #2 said Resident #1 was sitting on the side of the bed, she got behind him/her, did the Heimlich Maneuver and Resident #1 coughed up some food as Nurse #1 came into the room. CNA #2 said Nurse #1 took over and continued the Heimlich Maneuver on Resident #1 and he/she started coughing. CNA #2 said she did not see what type of food Resident #1 coughed up. During an interview on 01/16/25 at 2:49 P.M., (which included review of her written employee statement), Nurse #1 said she worked the 6:00 A.M. to 2:30 P.M. shift on 12/21/24. Nurse #1 said Resident #1 had a house chopped diet order and required staff supervision when eating meals. Nurse #1 said around 12:00 P.M. she heard a CNA yelling out for help, she ran into Resident #1's room and the CNA (exact name unknown) said he/she is choking. Nurse #1 said she saw Resident #1 sitting on the side of his/her bed in distress, his/her face was red, and he/she was struggling to breathe. Nurse #1 said she stood Resident #1 up, performed the Heimlich Maneuver on him/her and a piece of meat expelled from his/her mouth. Nurse #1 said she took Resident #1's vital signs, assisted into his/her bed to rest and said she notified the Administrator. During an interview on 01/14/25 at 3:51 P.M., the Unit Manager said when the food trucks are delivered to the units, the Nurses are responsible for checking all resident's meal tickets against the meal provided on their tray, prior to them being served to the residents, to make sure that residents are receiving the proper diet (food consistency). During interviews throughout the day of the survey, on 01/14/25 with CNA #1 and CNA #2, and on 01/15/25 with CNA #3, CNA #4, and CNA #5, who all worked on Resident #1's unit, said that Resident #1 ate all meals in his/her room and required supervision by staff with eating. During an interview on 01/14/25 at 5:13 P.M., the Director of Nursing (DON) said prior to meal trays being served to the residents, nurses are responsible for checking meal trays against resident's meal tickets to make sure they receive the correct meal. The DON said it is her expectation that all nurses check residents' meal trays before being passed to them. The DON said it is also her expectation that residents that need assistance/supervision with meals are provided the level of assistance they require from staff. During an in-person interview on 01/14/25 at 5:23 P.M. and a telephone interview on 01/16/25 at 11:38 A.M., the Administrator said on 12/21/24 Nurse #1 informed him that Resident #1 had choked on his/her lunch meal, and he started his investigation right away. The Administrator said he observed Resident #1's leftover lunch tray which contained one whole meatball still on his/her plate and his/her meal ticket on the tray indicated a house, chopped diet. The Administrator said Nurse #1 told him she had not checked Resident #1's meal tray or any of the other residents' trays at lunch prior to them being passed to residents and that a CNA had not assisted/stayed to supervise Resident #1 while he/she was eating. The Administrator said during his investigation which included interviews with staff, he was unable to determine which staff member gave Resident #1 his/her lunch tray and left him/her unassisted in his/her room. The Administrator said nurses are supposed to check all meal trays for accuracy prior to being served to residents, and that each meal is accurate according to the resident's meal ticket. On 01/14/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 12/21/24, Resident #1 was assessed by the nurse, the physician and hospice nurse were notified, a new order was obtained for a chest X-ray, mechanical soft texture diet and nectar thick liquids. B. On 12/23/24, Resident #1's level of assistance with eating was updated on his/her ADL Care/Kardex Plan and indicated he/she was a 1:1 feed.(assistance of one staff member to be fed). C. 12/23/24 through 12/31/24, the Unit Managers conducted a house wide audits on all units and reviewed what was indicated on each resident's current level of feeding assistance on their Care Plans/Kardex to ensure they were accurate and up to date. D. On 12/23/24, Nursing Management provided education to all Licensed Nursing Staff on meal tray accuracy, checking and ensuring the proper level of feeding assistance: Licensed nurses are required to check each tray before each meal service to ensure residents tray is accurate according to their meal ticket and CNAs must follow residents care plan regarding provision of the correct level of assistance. E. On 12/23/24, the Assistant Food Service Director provided education to all Dietary staff on meal tray accuracy: all resident meal trays are to be checked for complete accuracy according to their meal tickets prior to the trays leaving the kitchen to be delivered. F. On 12/23/24, the Dietary Department management started daily audits on all resident's meal trays for accuracy according to their meal tickets prior to the trays leaving the kitchen to be delivered. G. On 01/02/25, the Dietician provided education to all Dietary Staff cooks on meal service/texture modifications: description of textures and how to properly prepare and serve texture modified food to residents with swallowing difficulties or dexterity issues. H. The Nursing Department staff will conduct daily audits on verifying tray accuracy and ensuring proper level of feeding assistance for one month, then weekly for four weeks, then monthly for a minimum of two QAPI cycles. I. The Dietary Department management will conduct daily audits on resident's diet orders on the meal tickets is accurate to the meal being served for one month, then weekly for four weeks, then monthly for a minimum of two QAPI cycles. J. The results of the audits will be presented and reviewed at the quarterly QAPI meeting for a minimum of two quarters or until compliance is achieved. K. The Director of Nursing, Food Service Director, and/or designees are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose Plan of Care related to Activities of Daily Living (ADLs) indicated interventions included that he/she required continual supervision (staff member to be with him/her during entire task) with meals, the facility failed to ensure staff consistently implemented and followed interventions, when on 12/21/24, staff assistance was not provided as required, Resident #1 was served his/her lunch tray, left alone in his/her room while eating his/her meal, he/she choked on food and required the Heimlich Maneuver. Findings Include: Review of the Facility's Policy tilted, Care Planning-Comprehensive, dated as revised May 2017, indicated the following: -an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. -the Facility's Care Planning/Interdisciplinary Team (IDT) in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to maintain. -each resident comprehensive care plan incorporates identified problem areas, incorporates risk factors, builds on resident's strengths, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status, enhance the optimal functioning of the resident, reflect currently recognized standards of practice. -care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Resident #1 was admitted to the Facility in October 2019, diagnoses included Senile degeneration of the brain (neurological disorder that causes a decline in cognitive function), Dysphagia (difficulty swallowing), Gastro-esophageal reflux disease, feeding difficulties, Hyperlipidemia (high cholesterol), and Anxiety. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she had severe cognitive impairment. Review of Resident #1's Self Care Deficit Care Plan related to ADLs, renewed and reviewed with his/her November 2024 MDS, indicated that he/she required continual supervision with meals. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/21/24, indicated that at approximately 12:00 P.M. a Certified Nurse Aide (CNA) observed Resident #1 to be choking on his/her food, and he/she required the Heimlich Maneuver to dislodge the food. The Report indicated Resident #1 had not received assistance (supervision) with his/her meal (as required). Review of Resident #1's Nurse Progress Note, dated 12/23/24 (as a late entry for 12/21/24 and written by Nurse #1), indicated that Resident #1 was found by a Certified Nurse Aide (CNA) in his/her room choking while he/she was eating and this writer performed the Heimlich Maneuver, expelling a small piece of meatball from Resident #1's mouth. The Note indicated Resident #1's vital signs were taken, he/she was encouraged to cough and clear his/her throat with good effect, and he/she was then allowed to rest. During an interview on 01/15/25 at 10:04 A.M., (which included review of her written employee statement), Certified Nurse Aide (CNA) #3 said on 12/21/24, she was walking towards Resident #1's room, heard him/her struggling to cough and went into his/her room. CNA #3 said Resident #1 was sitting on the side of the bed, his/her meal tray was in front of him/her, his/her face was red and turning purple in color and she realized that he/she was choking. CNA #3 said she yelled out help he/she is choking and CNA #2 came into the room while CNA #1 went to get Nurse #1. CNA #3 said that CNA #2 got behind Resident #1, she (CNA #2) started the Heimlich Maneuver as Nurse #1 entered the room. CNA #3 said Nurse #1 and CNA #2 stood Resident #1 up, Nurse #1 took over doing the Heimlich Maneuver, and a piece of a meatball came up into his/her mouth. CNA #3 said when she entered Resident #1's room, there were no staff member present in the room supervising him/her while he/she was eating. During an interview on 01/16/25 at 2:49 P.M., (which included review of her written employee statement), Nurse #1 said Resident #1 had an order for a house chopped diet and required supervision by staff when eating his/her meals. Nurse #1 said on 12/21/24, around 12:00 P.M. she heard a CNA yelling out for help, she ran into Resident #1's room and the CNA (exact name unknown) said he/she is choking. Nurse #1 said she saw Resident #1 sitting on the side of his/her bed in distress, his/her face was red, and he/she was struggling to breathe. Nurse #1 said she stood Resident #1 up, performed the Heimlich Maneuver on him/her and a piece of meat expelled from his/her mouth. Nurse #1 said she took Resident #1's vital signs, assisted him/her into bed to rest and she notified the Administrator. Nurse #1 said that one of the CNAs had given Resident #1 his/her meal tray in his/her room and left him/her alone with his/her meal. During interviews throughout the day of the survey, on 01/14/25 with CNA #1 and CNA #2, and on 01/15/25 with CNA #3, CNA #4, and CNA #5, who all worked on Resident #1's unit, said that Resident #1 ate all meals in his/her room and required supervision by staff with eating. During an interview on 01/14/25 at 5:13 P.M., the Director of Nursing (DON) said her expectation is that residents that need assistance and/or supervision with meals that they be provided that assistance from staff and that staff did not follow Resident #1's plan of care. During an in-person interview on 01/14/25 at 5:23 P.M. and a telephone interview on 01/16/25 at 11:38 A.M., the Administrator said on 12/21/24 Nurse #1 informed him that Resident #1 had choked on his/her lunch meal and that a CNA had not assisted or stayed to supervise Resident #1 with his/her meal. The Administrator said during his investigation which included interviews with staff, he was unable to determine which staff member gave Resident #1 his/her lunch tray and left him/her unassisted in his/her room. On 01/14/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 12/21/24, Resident #1 was assessed by the nurse, the physician and hospice nurse were notified, a new order was obtained for a chest X-ray, mechanical soft texture diet and nectar thick liquids. B. On 12/23/24, Resident #1's level of assistance with eating was updated on his/her ADL Care/Kardex Plan and indicated he/she required 1:1 with meals, (assistance of one staff member while eating, being fed). C. 12/23/24 through 12/31/24, the Unit Managers conducted house wide audits on all units and reviewed what was indicated as each resident's current level of feeding assistance on their Care Plans/Kardex, to ensure they were accurate and up to date. D. On 12/23/24, Nursing Management provided education to all Licensed Nursing Staff on meal tray accuracy, checking and ensuring the proper level of feeding assistance, Licensed nurses are required to check each tray before each meal service to ensure residents tray is accurate according to their meal ticket and CNAs must follow residents care plan regarding provision of the correct level of assistance. E. The Nursing Department staff will conduct daily audits on verifying tray accuracy and ensuring proper level of feeding assistance for one month, then weekly for four weeks, then monthly for a minimum of two QAPI cycles. F. The results of the audits will be presented and reviewed at the quarterly QAPI meeting for a minimum of two quarters or until compliance is achieved. G. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of dysphagia (difficulty swallowing) and required an altered texture diet, the Facility failed to ensure meals prepared and served to him/her met his/her individual needs and physicians orders for diet. On 12/21/24 dietary staff preparing his/her lunch time meal tray did not put the correct texture of food on his/her tray, Resident #1 was observed choking on his/her food and required the Heimlich Maneuver to dislodge the food. Findings Include: Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: -each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs -food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident -if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/21/24, indicated that on 12/21/24, at approximately 12:00 P.M. a Certified Nurse Aide (CNA) observed Resident #1 to be choking on his/her food, and he/she required the Heimlich Maneuver to dislodge the food. The Report indicated that Resident #1's lunch meal was not prepared by the cook according to his/her diet, nursing staff did not check his/her meal tray for accuracy according to his/her meal ticket and he/she was served the incorrect meal texture. Resident #1 was admitted to the Facility in October 2019, diagnoses included senile degeneration of the brain (neurological disorder that causes a decline in cognitive function), dysphagia (difficulty swallowing), gastro-esophageal reflux disease, feeding difficulties, hyperlipidemia (high cholesterol), and anxiety. Review of Resident #1's Physician's Orders, dated December 2024, indicated he/she required a House regular diet, food to be chopped. Review of Resident #1's Nutrition/Dietary Progress Note, dated 11/04/24, indicated that his/her diet order was a house regular chopped with thin liquids. During an interview on 01/14/25 at 4:14 P.M., the Dietician said Resident #1 had a diagnosis of Dysphagia and on a house chopped with thin liquid diet order. The Dietician said on 12/21/24 Resident #1 was served whole Swedish meatballs for lunch which was not appropriate for him/her because the meatballs should have been chopped up. Review of the Facility's Dietary Menu, dated 12/21/24, indicated the following meal was on the menu to be served for lunch: -Swedish meatballs, egg noodles, and carrots. Review of Resident #1's Lunch meal ticket, dated 12/21/24, indicated that he/she required a House Chopped diet and noted under his/her preferences all meals were to be chopped. During an interview on 01/14/25 at 1:03 P.M., Dietary Aide #2 said he worked 6:00 A.M. to 2:30 P.M. on 12/21/24 and called out all the residents' lunch diet orders to the Cook. Dietary Aide #2 said the lunch meal was Swedish meatballs, egg noodles, carrots and he remembered calling out Resident #1's diet order as being house chopped from his/her meal ticket to the Cook. Dietary Aide #2 said when the [NAME] handed him Resident #1's plate, he saw that the meatballs on his/her plate were whole, not chopped up and said he asked the [NAME] if the meal was appropriate for Resident #1 who had a chopped diet. Dietary Aide #2 said the [NAME] told him that it was okay to give the meal to Resident #1 and he put the plate on his/her tray in the food truck and covered it. During an interview on 01/14/25 at 1:30 P.M., the [NAME] said the Dietary Aide that is assigned to the food truck calls out resident's diets, any allergies, preferences and dislikes from their meal tickets to the Cook, the [NAME] prepares the appropriate meal plate according to the diet order called out by the Dietary Aide, and the Dietary Aide is supposed to double check the resident's meal ticket to ensure the diet order is correct prior to placing the meal plate on the tray. The [NAME] said on 12/21/24 she prepared the lunch meal which was Swedish meatballs over egg noodles with diced carrots and that Dietary Aide #2 called out the resident's diet orders to her. The [NAME] said Dietary Aide #2 did call out Resident's #1's diet as a house chopped and she told Dietary Aide #2 that chopped and regular diets would be the same set-up for the lunch meal. The [NAME] said she had been directed in the past to serve the Swedish meatballs with egg noodles meal as a regular diet and that the meatballs are not chopped up. The [NAME] said she made the decision to serve the lunch meal as a regular diet to Resident #1 and that Dietary Aide #2 that was going by her directive. The [NAME] said Resident #1's meal ticket indicated under preferences all meals chopped and that the meatballs should have been chopped up. During an interview on 01/14/25 at 4:47 P.M., the Assistant Food Service Director (AFSD) said a Dietary Aide calls out all resident's diet orders to the Cook, the [NAME] prepares the meal plate, and hands the plate back to the Dietary Aide. The AFSD said the Dietary Aide is supposed to check the meal on the plate to the resident's meal ticket to make sure the meal is correct, then places the plate on the tray in the food truck. The AFSD said Resident #1 had a house chopped diet order and on 12/21/24 he/she received whole meatballs that should have been chopped according to his/her diet order. During an interview on 01/16/25 at 2:49 P.M., (which included review of her written employee statement), Nurse #1 said she worked the 6:00 A.M. to 2:30 P.M. shift on 12/21/24. Nurse #1 said she had not checked Resident #1's lunch meal tray against his/her meal ticket before he/she received his/her tray. Nurse #1 said she had not been trained and was unaware at that time (12/21/24) that it was the nurses' responsibility to check all resident's meal trays before they received them. Nurse #1 said Resident #1 had a house chopped diet order and required continual supervision with eating his/her meals. Nurse #1 said around 12:00 P.M. she heard a CNA yelling out for help, she ran into Resident #1's room and the CNA (exact name unknown) said he/she is choking. Nurse #1 said she saw Resident #1 sitting on the side of his/her bed in distress, his/her face was red, and he/she was struggling to breathe. Nurse #1 said she stood Resident #1 up, performed the Heimlich Maneuver on him/her and a piece of meat expelled from his/her mouth. Nurse #1 said she took Resident #1's vital signs, put him/her into his/her bed to rest and said she notified the Administrator. During an interview on 01/14/25 at 5:13 P.M., the Director of Nursing (DON) said nurses are responsible for checking meal trays against resident's meal tickets to make sure they receive the correct meal and that it is her expectation that all nurses check residents' meal trays before being passed to them. During an in-person interview on 01/14/24 at 5:23 P.M. and a telephone interview on 01/16/25 at 11:38 A.M., the Administrator said on 12/21/24 Nurse #1 informed him that Resident #1 had choked on his/her lunch meal, and he started his investigation right away. The Administrator said he observed Resident #1's leftover lunch tray which contained one whole meatball still on his/her plate and his/her meal ticket on the tray indicated a house, chopped diet. The Administrator said Nurse #1 told him she had not checked Resident #1's meal tray or any of the other residents' trays at lunch prior to them being passed to residents. The Administrator said the [NAME] told him she had served Resident #1 the Swedish meatballs whole because it was her understanding that was how they should be served, and she (the Cook) said the meatballs should have been chopped according to Resident #1's diet order. The Administrator said his expectation is that Dietary staff should be verifying resident's prepared meal plates to the resident's meal ticket to ensure all residents receive the correct diet order. On 01/14/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 12/21/24, Resident #1 was assessed by the nurse, the physician and hospice nurse were notified, a new order was obtained for a chest X-ray, mechanical soft texture diet and nectar thick liquids. B. On 12/23/24, the Assistant Food Service Director provided education to all Dietary staff on meal tray accuracy: all resident meal trays are to be checked for complete accuracy according to their meal tickets prior to the trays leaving the kitchen to be delivered. C. On 12/23/24, Nursing Management provided education to all Licensed Nursing Staff on meal tray accuracy, checking and ensuring the proper level of feeding assistance: Licensed nurses are required to check each tray before each meal service to ensure residents tray is accurate according to their meal ticket and CNAs must follow residents care plan regarding provision of the correct level of assistance. D. On 12/23/24, the Dietary Department management started daily audits on all resident's meal trays for accuracy according to their meal tickets prior to the trays leaving the kitchen to be delivered. E. On 01/02/25, the Dietician provided education to all Dietary Staff cooks on meal service/texture modifications: description of textures and how to properly prepare and serve texture modified food to residents with swallowing difficulties or dexterity issues. F. The Dietary Department management will conduct daily audits on resident's diet orders on the meal tickets are accurate to the meal being served for one month, then weekly for four weeks, then monthly for a minimum of two QAPI cycles. G. The Nursing Department staff will conduct daily audits on verifying tray accuracy by checking each tray before each meal service to ensure resident's trays are accurate according to their meal tickets for one month, then weekly for four weeks, then monthly for a minimum of two QAPI cycles. H. The results of the audits will be presented and reviewed at the quarterly QAPI meeting for a minimum of two quarters or until compliance is achieved. I. The Director of Nursing, Food Service Director, and/or designees are responsible for overall compliance.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure they were provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2 who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left hip which required surgical intervention to repair. 2) On 08/03/24, CNA #1 transferred Resident #1 from his/her wheelchair into bed, without getting assistance from another staff member, Resident #1 complained of left ankle pain after the transfer and was diagnosed by an orthopedic physician with a second or third degree (partial to complete tear of the ankle ligament) left ankle lateral sprain which required a brace for comfort. Findings include: Review of the Facility's Policy, titled Falls Policy and Procedure, dated as reviewed December 2023, indicated the following: -fall assessment will be completed upon admission/readmission, after each fall, with any change in medical condition, quarterly and annually; a score of 10 or greater indicates high risk for fall; -licensed nurse must implement interventions to promote resident safety based on the residents risk factors; -if identified as high risk, resident may be placed on the falling star program; -interventions will be added to the resident's care plan and ADL card; -any resident fall is to be reported to the nurse immediately; -resident is to be left as found, not moved until the nurse has completed the assessment; -nursing supervisor on duty shall be notified; -vital signs are to be taken for 48 hours and observations recorded in the nurses' notes; -charge nurse will notify the resident's guardian or responsible party of the fall; -the physician must be notified; -the nurse shall complete the following documentation: fall and initial assessment findings in the nurses notes, the fall in the shift report log book, conduct re-assessment of the resident's fall risk by completing a Fall Assessment, complete the Quality Assessment and Assurance Incident Report, update the care plan and ADL card to include additional falls prevention interventions implemented; - the Quality Assessment and Assurance Incident Report and Post Falls Investigation Report will be forwarded to the Director of Nursing. Review of the Facility's Policy, titled Resident Accident Reporting Procedure, dated as reviewed January 2024, indicated the following: -an accident is defined as any episode which results in visible signs of injury, any resident on the floor, witnessed falls or one in which follow-up treatment or evaluation is necessary; -Licensed Nurses complete the Quality Assessment and Assurance Incident Report; -Report only factual data as seen by yourself or the individual reporting to you; -complete pertinent resident information; -record date and time of accident; -assess resident's condition, identify any potential contributing factors to the accident; -describe in detail and to the extent known, the act and circumstances regarding the accident; -identify any witnesses, and request witness write a statement; -nurse will conduct resident assessment and document symptoms and predisposing factors; -nurse will notify the physician, responsible party and supervisor; -write a nurses note, document change of shift report, monitor and observations recorded in nurses notes for 48 hours; -address in care plan and ADL card; -document all communication with physician; -nurse will modify the care plan as necessary to include measures and interventions initiated to prevent similar accidents. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included: cerebral infarction, bilateral carotid arteries occlusion and stenosis, pneumonitis due to inhalation of food, major depressive disorder, weakness, epilepsy, respiratory failure with hypoxia and dementia. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment and was totally dependent on staff with rolling from side to side in bed. Review of Resident #2's Care Plan related to Mobility, renewed and reviewed with his/her June 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with repositioning in bed. Review of Resident #2's Resident Care Card/Kardex, (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility, which included turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 08/06/24, indicated that on 08/05/24 at 9:10 P.M., a CNA was providing care to Resident #2, turned him/her over onto his/her right side in bed and proceeded to go into the bathroom [leaving him/her unattended] to get water to wash Resident #2. The Report indicated that when the CNA walked into the bathroom, she heard a bang and when she went to check on Resident #2, Resident #2 was lying on the floor beside his/her bed on his/her left side. The Report indicated that Resident #2 was observed to have a bump to the left side of his/her forehead and a bruise to his/her left ankle and left ear. The Report indicated that Resident #2 required the assistance of two staff members with care. The Report indicated that Resident #2 was transferred to the Hospital ED for evaluation and was diagnosed with a left hip fracture. Review of a Nurse Progress Note, dated 08/05/24 (written by Nurse #3) indicated that a CNA (later identified as CNA #2) called her into Resident #2's room, and he/she (Resident #2) was observed on the floor and had hit his/her head on the night stand. The Note indicated that Resident #2 had a large bruise to his/her left ankle, left ear and continued to cry out. The Note indicated that 911 (Emergency Medical Services) was called and Resident #2 was transferred to the Hospital ED. During a telephone interview on 08/28/24 at 12:22 P.M., (which included review of her written witness statement), Nurse #3 said that on 08/05/24, another nurse notified her that Resident #2 was on the floor. Nurse #3 said she immediately ran into Resident #2's room and found him/her lying on the floor with his/her head on the foot of the bedside table, yelling out in pain. Nurse #3 said that the bed was in the high position when she walked into Resident #2's room. Nurse #3 said she asked CNA #2 what happened and said that CNA #2 told her, she was providing care to Resident #2, turned him/her on his/her right side, walked away from him/her to go get clean water in the bathroom, heard a loud noise when she came out of the bathroom, that Resident #2 was on the floor and had fallen out of bed. Nurse #3 said that Resident #2 was yelling out in pain, had an abrasion to his/her left ear and a bruise to his/her left ankle. Nurse #3 said that Resident #2 required physical assistance of two staff members with bed mobility and said CNA #2 should have had another staff member present to assist her with Resident #2's care. Nurse #3 said that 911 was called and Resident #2 was transferred to the Hospital for evaluation of his/her injuries and returned to the Facility several days later with a new diagnosis of a fractured left hip. Review of CNA #2's Written Witness Statement, dated 08/05/24, indicated that she was providing care to Resident #2 in bed, turned him/her on the right side, went into the bathroom to change the water and heard a loud bang noise when she was in the bathroom. The Statement indicated that when she (CNA #2) walked out of the bathroom she saw Resident #2 lying on the floor on his/her left side. During a telephone interview on 8/28/24 at 12:40 P.M., CNA #2 said that she was providing care to Resident #2 in bed and turned him/her on his/her right side in bed. CNA #2 said that she walked into the bathroom to get clean water and just as she was coming out of the bathroom, she heard a loud bang noise and saw Resident #2 lying on the floor on his/her left side. CNA #2 said that she knew that Resident #2 required physical assistance of two staff members with bed mobility which included turning and repositioning in bed. CNA #2 said that she had taken care of Resident #2 prior to the incident and said she thought she could provide care to Resident #2 in bed by herself. CNA #2 said she did not have another staff member with her when she provided care to Resident #2. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #2 required physical assistance of two staff members with bed mobility, turning and positioning and said CNA #2 provided care to him/her without the assistance of another staff member and should not have. Review of a Hospital Discharge Summary, dated 08/09/24, indicated that Resident #2 fell out of bed at the nursing facility and sustained an acute left intertrochanteric femoral fracture (hip). The Summary indicated that Resident #2 underwent an Open Reduction Internal Fixation (ORIF) surgical repair of his/her left hip. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #2 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #2 provided care to Resident #2 in bed without the assistance of another staff member and Resident #2 fell out of bed and sustained a left hip fracture. 2) Resident #1 was admitted to the Facility in August 2023 diagnoses included: sepsis, osteoarthritis of knee, acute on chronic respiratory failure, dizziness, abnormalities of gait and mobility and muscle weakness. Review of Resident #1's Fall Assessment, dated 07/02/24, indicated that he/she was at high risk for falls. Review of Resident #1's Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was totally dependent on staff with transfers. Review of Resident #1's Care Plans related to Self-Care Deficit and Fall Risk, reviewed and renewed with the completion of his/her July 2024 MS, indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of Resident #1's Resident Care Card/Kardex, (used as a reference guide by CNA's), indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of the Facility's Internal Investigation Report, dated 08/09/24, indicated that on 08/03/24 at approximately 7:00 P.M., a CNA was transferring Resident #1 from wheelchair to bed when Resident #1 pivoted incorrectly while transferring and twisted his/her left ankle. The Report indicated that on 08/04/24, Resident #1 complained of left ankle pain, upon assessment the left ankle was noted to be swollen and bruised, the physician was notified, and an x-ray was obtained. The Report indicated that the results of the x-ray were negative for any fracture. The Report indicated that on 08/08/24, Resident #1 was transferred to the hospital for complaints of stomach and head pain and on 08/09/24, the Administrator received a report from the hospital that indicated that Resident #1 complained of left ankle pain, an x-ray was obtained and revealed a fracture to his/her left ankle. The Report indicated that on 8/16/24, Resident #1 was seen by an orthopedic surgeon, an x-ray was obtained of his/her left ankle and was negative for a fracture. The Report indicated that Resident #1 had a second or third degree left ankle lateral sprain. Review of Nurse Progress Note, dated 8/06/24 as a late entry for 08/04/24, (written by Nurse #2) indicated that Resident #1 complained of pain and screamed out in pain when his/her left ankle was touched by nurse during assessment. The Note indicated that Resident #1's left ankle was noted to be bruised, discolored and swollen. The Note indicated that the physician was notified, ordered an x-ray of Resident #1's left ankle and ice to the left ankle. During a telephone interview on 08/28/24 at 12:54 P.M., Nurse #2 said that on 08/04/24 Resident #1 complained of left ankle pain and upon assessment, his/her left ankle was bruised and swollen. Nurse #2 said she notified the physician and obtained an order for an x-ray and ice pack. Nurse #2 said that Resident #1 told her that a male CNA (later identified as CNA #1) transferred him/her to bed by himself the night before (08/03/24) and that he/she (Resident #1) twisted his/her left ankle during the transfer. Nurse #2 said that she asked CNA #1 if he transferred Resident #1 alone and if during the transfer Resident #1 complained of pain and said CNA #1 told her that Resident #1 said Ow during the transfer. Nurse #2 said that Resident #1 requires the physical assistance of two staff members for transfers. During a telephone interview on 8/28/24 at 11:49 A.M., (which included review of his written witness statement), CNA #1 said that on 08/03/24 he transferred Resident #1 alone from his/her wheelchair into bed and that Resident #1 hit his/her left ankle on the wheelchair. CNA #1 said Resident #1 complained of left ankle pain during and after the transfer and said he reported it to the nurse. CNA #1 said that he was aware that Resident #1 required the assistance of two staff members with transfers and said he thought he could transfer Resident #1 back into bed alone without the assistance of another staff member. During a telephone interview on 08/27/24 at 12:15 P.M., (which included review of her written witness statement), Nurse #1 said that on 08/03/24, CNA #1 had reported to her that Resident #1 complained of leg pain and wanted Tylenol, but said that CNA #1 did not report to her that Resident #1 had hit his/her left ankle on the wheelchair during the transfer. Nurse #1 said that Resident #1 requires physical assistance of two staff members with all transfers. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #1 required physical assistance of two staff members with transfers. The Unit Manager said CNA #1 transferred Resident #1 without assistance from another staff member and should not have. Review of an Orthopedic Consult Report, dated 08/16/24, indicated that Resident #1 had a second or third degree left ankle lateral sprain. The Report indicated that Resident #1 was to wear a stirrup (used to increase comfort and limit movement after an injury) brace for comfort. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #1 required the physical assistance of two staff members with transfers. The DON said that CNA #1 transferred Resident #1 without assistance from another staff member and said Resident #1 sustained a sprained left ankle during the transfer. On 08/27/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 08/03/24, Resident #1 was given Tylenol for complaints of leg pain. B. On 08/04/24, Resident #1 was assessed by the nurse, physician was notified of bruising and swelling to left ankle, an x-ray was obtained, ice and Tylenol were implemented. C. On 08/05/24, Resident #2 was assessed, first aid was initiated, 911 was called and he/she was transferred to the ED for evaluation of his/her injuries. D. On 08/09/24, a full house audit was conducted by the Unit Managers of all Resident ADL/Kardex's and Care Plans to ensure accuracy, and that the correct level of assistance required by staff for ADL's was indicated. E. On 08/09/24, Resident #2 was readmitted to the Facility from the hospital and his/her Plan of Care was updated. F. On 08/09/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on the Use of the Resident ADL Guide and Care Kardex. G. On 8/12/24, staff nurses began observing CNA staff daily on transfers and positioning of residents per interventions identified in their plans of care. H. On 08/13/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on safe lifting and movement of residents. I. On 08/16/24, Resident #1's was seen by the Orthopedic Surgeon and was found to have a second or third degree left ankle sprain and new orders for a stirrup brace was implemented. J. On 08/16/24, the Facility implemented a readmission policy to ensure all paperwork is reviewed and accurate on all new admissions and readmissions. Unit Managers are responsible to complete the checklist daily at morning meeting. K. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Resident Care Plans and ADL Guide/Kardex's to ensure accuracy. L. The results of the audits will be forwarded to the Corporate Director of Clinical Services weekly. M. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. N. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), whose Plans of Care indicated that they required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in their Plans of Care while meeting his/her care needs. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2, who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left hip which required surgical intervention to repair. 2) On 08/03/24, CNA #1 transferred Resident #1 from his/her wheelchair into bed, without getting assistance from another staff member. Resident #1 complained of left ankle pain after the transfer, and was diagnosed by an orthopedic physician with a second or third degree (partial to complete tear of the ankle ligament) left ankle lateral sprain which required a brace for comfort. Findings include: Review of the Facility's Policy, titled Care Plans Policy, dated as revised May 2017, indicated the following: -an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident; -the Facility's Care Planning/Interdisciplinary Team (IDT) in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to maintain; -each resident comprehensive care plan incorporates identified problem areas, incorporates risk factors, builds on resident's strengths, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status, enhance the optimal functioning of the resident, reflect currently recognized standards of practice; -care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes; -assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes; -the Care Planning/IDT team is responsible for the review and updating of care plans when there has been a significant change in the resident's conditions, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly. Review of the Facility's Policy, titled Resident ADL Guide/Kardex, dated as reviewed December 2023, indicated the following: -CNA's are provided with a complete and updated reference source for resident care needs upon admission and throughout length of stay; -upon admission, the Resident ADL Guide Kardex is to be completed by the Admitting Nurse to enter into Point of Care (POC) in Net Solutions (Electronic Medical Record); -ADL Kardex are to be assigned in POC for designated CNA assignments; -CNA's are to check their residents Kardex in POC prior to starting their assignment and refer to Kardex in POC periodically throughout their assigned shift; -ADL Kardex's are to be reviewed and updated at Case Management/Care Plan meetings. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included: cerebral infarction, bilateral carotid arteries occlusion and stenosis, pneumonitis due to inhalation of food, major depressive disorder, weakness, epilepsy, respiratory failure with hypoxia and dementia. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment and was totally dependent on staff with rolling from side to side in bed. Review of Resident #2's Care Plan related to Mobility, renewed and reviewed with his/her June 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with repositioning in bed. Review of Resident #2's Resident Care Card/(Kardex, (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility, which included turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 08/06/24, indicated that on 08/05/24 at 9:10 P.M., a CNA was providing care to Resident #2, turned him/her over onto his/her right side in bed and proceeded to go into the bathroom to get water [leaving him/her unattended] to wash Resident #2. The Report indicated that when the CNA walked into the bathroom, she heard a bang and when she went to check on Resident #2, Resident #2 was lying on the floor beside his/her bed on his/her left side. The Report indicated that Resident #2 was observed to have a bump to the left side of his/her forehead and a bruise to his/her left ankle and left ear. The Report indicated that Resident #2 required the assistance of two staff members with care. The Report indicated that Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a left hip fracture. Review of a Nurse Progress Note, dated 08/05/24 (written by Nurse #3) indicated that a CNA (later identified as CNA #2) called her into Resident #2's room, he/she (Resident #2) was observed on the floor and had hit his/her head on the night stand. The Note indicated that Resident #2 had a large bruise to his/her left ankle, left ear and continued to cry out. The Note indicated that 911 (Emergency Medical Services) was called and Resident #2 was transferred to the Hospital. During a telephone interview on 08/28/24 at 12:22 P.M., (which included review of her written witness statement), Nurse #3 said that on 08/05/24, another nurse notified her that Resident #2 was on the floor. Nurse #3 said she immediately ran into Resident #2's room and found him/her lying on the floor with his/her head on the foot of the bedside table, yelling out in pain. Nurse #3 said that the bed was in the high position when she walked into Resident #2's room. Nurse #3 said she asked CNA #2 what happened and said that CNA #2 told her that she was providing care to Resident #2, turned him/her on his/her right side, walked away from him/her to go get clean water in the bathroom, and he/she fell out of bed. Nurse #3 said that Resident #2 was yelling out in pain, had an abrasion to his/her left ear and a bruise to his/her left ankle. Nurse #3 said that Resident #2 required the physical assistance of two staff members with bed mobility and said CNA #2 did not follow Resident #2's plan of care. Review of CNA #2's Written Witness Statement, dated 08/05/24, indicated that she was providing care to Resident #2 in bed, turned him/her on the right side, went into the bathroom to change the water and heard a loud bang when she walked out of the bathroom and saw Resident #2 lying on the floor on his/her left side. During a telephone interview on 8/28/24 at 12:40 P.M., CNA #2 said that she was providing care to Resident #2 in bed and turned him/her on his/her right side in bed. CNA #2 said that she walked into the bathroom to get clean water and just as she was coming out of the bathroom, she heard a loud bang noise and saw Resident #2 lying on the floor on his/her left side. CNA #2 said she had taken care of Resident #2 prior to this incident, and that she knew that Resident #2 required physical assistance of two staff members with bed mobility including turning and repositioning in bed. CNA #2 said that she thought she could provide care to Resident #2, in bed, by herself. CNA #2 said she did not have another staff member with her when she provided care to Resident #2 care and said she did not follow Resident #2's plan of care. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #2 required physical assistance of two staff members with bed mobility, turning and positioning. The Unit Manager said CNA #2 provided care to Resident #2 in bed without the assistance of another staff member and did not follow Resident #2's plan of care. Review of a Hospital Discharge Summary, dated 08/09/24, indicated that Resident #2 fell out of bed at the nursing facility and sustained an acute left intertrochanteric femoral fracture (hip). The Summary indicated that Resident #2 underwent an Open Reduction Internal Fixation (ORIF) surgical repair of his/her left hip. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #2 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #2 provided care to Resident #1 in bed without the assistance of another staff member, and Resident #2 fell out of bed and sustained a left hip fracture. The DON said that CNA #2 did not follow Resident #2's plan of care and said that it was her expectation that staff follow the plan of care. 2) Resident #1 was admitted to the Facility in August 2023 diagnoses included: sepsis, osteoarthritis of knee, acute on chronic respiratory failure, dizziness, abnormalities of gait and mobility and muscle weakness. Review of Resident #1's Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was totally dependent on staff with transfers. Review of Resident #1's Care Plans related to Self-Care Deficit and Fall Risk, reviewed and renewed in conjunction with his/her July 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of Resident #1's Resident Care Card/Kardex, (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of the Facility's Internal Investigation Report, dated 08/09/24, indicated that on 08/03/24 at approximately 7:00 P.M., a CNA was transferring Resident #1 from wheelchair to bed when Resident #1 pivoted incorrectly while transferring and twisted his/her left ankle. The Report indicated that on 08/04/24, Resident #1 complained of left ankle pain, upon assessment the left ankle was noted to be swollen and bruised, the physician was notified, and an x-ray was obtained. The Report indicated that the results of the x-ray were negative for any fracture. The Report further indicated that on 08/08/24, Resident #1 was transferred to the hospital for complaints of stomach and head pain, and that on 08/09/24, the Administrator received a report from the hospital that indicated that Resident #1 complained of left ankle pain, an x-ray was obtained and revealed a fracture to his/her left ankle. The Report indicated that on 8/16/24, Resident #1 was seen by an orthopedic surgeon, an x-ray was obtained of his/her left ankle and was negative for a fracture. The Report indicated that Resident #1 had a second or third degree left ankle lateral sprain. Review of Nurse Progress Note, dated 8/06/24 as a late entry for 08/04/24, (written by Nurse #2) indicated that Resident #1 complained of pain and screamed out in pain when left ankle was touched by nurse during assessment. The Note indicated that Resident #1's left ankle was noted to be bruised, discolored and swollen. The Note indicated that the physician was notified, ordered an x-ray of Resident #1's left ankle and ice to the left ankle. During a telephone interview on 08/28/24 at 12:54 P.M., Nurse #2 said that on 08/04/24 Resident #1 complained of left ankle pain and upon assessment his/her left ankle was bruised and swollen. Nurse #2 said she notified the physician and obtained an order for an x-ray and ice pack. Nurse #2 said that Resident #1 told her that a male CNA (later identified as CNA #1) transferred him/her to bed by himself the night before (08/03/24) and that he/she (Resident #1) twisted his/her left ankle during the transfer. Nurse #2 said that she asked CNA #1 if he had transferred Resident #1 alone and if during the transfer Resident #1 complained of pain and said CNA #1 told her that Resident #1 said Ow during the transfer. Nurse #2 said that Resident #1 requires physical assistance of two staff members with transfers and said CNA #1 did not follow his/her plan of care. Nurse #2 said that Resident #1 sustained a bad left ankle sprain during the transfer. During a telephone interview on 8/28/24 at 11:49 A.M., (which included review of his written witness statement), CNA #1 said that on 08/03/24 he transferred Resident #1 alone from his/her wheelchair into bed and that Resident #1 hit his/her left ankle on the wheelchair. CNA #1 said Resident #1 complained of left ankle pain during and after the transfer and said he reported it to the nurse. CNA #1 said that he was aware that Resident #1 required the assistance of two staff members with transfers and said he thought he could transfer Resident #1 back into bed alone without the assistance of another staff member. CNA #1 said that he did not follow Resident #1's plan of care. During a telephone interview on 08/27/24 at 12:15 P.M., (which included review of her written witness statement), Nurse #1 said that on 08/03/24, CNA #1 had reported to her that Resident #1 complained of leg pain and wanted Tylenol. but said that CNA #1 did not report to her that Resident #1 had hit his/her left ankle on the wheelchair during the transfer. Nurse #1 said that Resident #1 requires physical assistance of two staff members with all transfers. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #1 required physical assistance of two staff members with transfers. The Unit Manager said CNA #1 transferred Resident #1 without the assistance of another staff member and did not follow Resident #1's plan of care. Review of an Orthopedic Consult Report, dated 08/16/24, indicated that Resident #1 had a second or third degree left ankle lateral sprain. The Report indicated that Resident #1 was to wear a stirrup (used to increase comfort and limit movement after an injury) brace for comfort. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #1 required the physical assistance of two staff members with transfers. The DON said that CNA #1 transferred Resident #1 without the assistance of another staff member and said Resident #1 sustained a sprained left ankle during the transfer. The DON said that CNA #1 did not follow Resident #1's plan of care. On 08/27/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 08/03/24, Resident #1 was given Tylenol for complaints of leg pain. B. On 08/04/24, Resident #1 was assessed by the nurse, physician was notified of bruising and swelling to left ankle, an x-ray was obtained, ice and Tylenol were implemented. C. On 08/05/24, Resident #2 was assessed, first aid was initiated, 911 was called and he/she was transferred to the ED for evaluation of his/her injuries. D. On 08/09/24, a full house audit was conducted by the Unit Managers of all Resident ADL/Kardex's and Care Plans to ensure accuracy, and that the correct level of assistance required by staff for ADL's was indicated. E. On 08/09/24, Resident #2 was readmitted to the Facility from the hospital and his/her Plan of Care was updated. F. On 08/09/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on the Use of the Resident ADL Guide and Care Kardex. G. On 8/12/24, staff nurses began observing CNA staff daily on transfers and positioning of residents per interventions identified in their plans of care. H. On 08/13/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on safe lifting and movement of residents. I. On 08/16/24, Resident #1's was seen by an Orthopedic Surgeon and was found to have a second or third degree left ankle sprain and new orders for a stirrup brace was implemented. J. On 08/16/24, the Facility implemented a readmission policy to ensure all paperwork is reviewed and accurate on all new admissions and readmissions. Unit Managers are responsible to complete the checklist daily at morning meeting. K. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Resident Care Plans and ADL Guide/Kardex's to ensure accuracy. L. The results of the audits will be forwarded to the Corporate Director of Clinical Services weekly. M. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. N. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right elbow, the Facility failed to ensure he/she was provided care and treatment that met professional standards for quality of care, when after a follow-up appointment, Resident #1's orthopedic Physician Assistant (PA) made recommendations on the consult form for Nursing to remove the splint and change his/her right elbow dressing daily, until healed. However, the recommendations were not followed up on or implemented by Nursing, the dressing changes were not completed and at his/her next orthopedic follow-up appointment is was discovered that Resident #1 had developed a pressure injury to his/her right elbow. 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 both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in February 2024, diagnoses included displaced fracture of lateral end of right clavicle (collarbone), unspecified fall, chronic kidney disease stage 3, diabetes mellitus, Bell's palsy and a displaced fracture of olecranon (elbow) process intraarticular extension of right ulna (long bone in the forearm). Review of Resident #1's Norton Scale Predicting Risk of Pressure Ulcer, dated 03/04/24, indicated he/she was assessed by nursing to be at high risk for the development of pressure injuries. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 03/07/24, indicated that Resident #1 had moderate cognitive impairments and he/she was at increased risk for the development of pressure injuries. Review of Resident #1's Orthopedic Report of Consultation, dated 03/18/24, indicated their recommendations included the following: -Continue with posterior (used to immobilize the elbow) splint -May remove splint for gentle Active Range of Motion (AROM) and Passive Range of Motion (PROM) -Non-weight bearing of right upper extremity -Change right elbow skin tear dressing daily until healed -Follow-up in 3 weeks Review of Resident #1's Weekly Skin Assessments, dated 03/08/24, 03/19/24, 03/26/24, and 04/05/24, indicated that nursing documented that he/she did not have any skin impairments other than multiple bruised areas that were previously identified due to a fractured right clavicle and right olecranon. Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 04/08/24, indicated that on 03/18/24, Resident #1 had an orthopedic appointment with orders to change right elbow skin tear dressing daily. The Report indicated that on 4/08/24 Resident #1 had another orthopedic appointment where he/she was noted to have 1 centimeter (cm) x 1 cm x 0.3 cm stage 4 (full-thickness skin loss with extensive destruction, tissue death or damage to muscle, bone or supporting structures) wound to his/her right elbow. The Report indicated Resident #1 had previously had an order for the splint to be worn on his/her right arm which stated not to remove or get the splint wet. The Report indicated that the nurse who had Resident #1 on her assignment on 3/18/24 did not follow up on the new orders {recommendations} given from the orthopedic appointment. Review of Resident #1's Nurse Progress Note, dated 3/18/24, (written by Nurse #2), indicated that he/she had a splint placed to the right arm, positive Circulation Sensation Motion (CSM) and ortho appointment. Review of Nurse #2's Written Witness Statement, dated 4/10/24, (provided to the Surveyor on the date of the survey), indicated that Resident #1 returned from an orthopedic appointment {on 3/18/24} and the consultation report was placed on the nursing desk. The Statement indicated that Nurse #2 forgot to look at the report for new orders. Review of Nurse #2's second Written Witness Statement, dated 4/11/24, (copy provided via fax to the Surveyor on 5/07/24), indicated that Resident #1 was at an orthopedic appointment {on 3/18/24} and the consultation report was placed on the unit desk. The Statement indicated that she (Nurse #2) was doing her medication pass when Resident #1 arrived back on the unit from the appointment. The Statement indicated that at the end of her (Nurse #2) shift while giving report to the overnight nurse, that her report included that Resident #1 went to an orthopedic appointment, and that she (Nurse #2) had verbalized to the overnight nurse that she had not looked at the paperwork from the orthopedic appointment. The Statement indicated that the overnight nurse agreed to review Resident #1's orthopedic consult paperwork. The Statement indicated that Nurse #2 showed the overnight nurse where the orthopedic consult paperwork was and placed the orthopedic consult paperwork in front of the computer. During a telephone interview on 05/06/24 at 2:35 P.M., Nurse #2 said that Resident #1 returned from an Orthopedic appointment on 03/18/24 with paperwork from his/her Orthopedic Consult during her shift (3:00 P.M. to 10:00 P.M.). Nurse #2 said that she placed the paperwork on the nurse's desk near the Unit Managers computer. Nurse #2 said that she was too busy at that time to review the Orthopedic Consult paperwork. Nurse #2 said that she told the overnight nurse (later identified as Nurse #1 who worked the 10:00 P.M. to 6:00 A.M. shift on 03/18/24 into 03/19/24) that Resident #1 had returned from an Orthopedic appointment, that the paperwork was at the nurse's desk and that she did not have time to review the paperwork for any new recommendations. Nurse #2 said that the next shift nurse (Nurse #1) told her that she would review the Orthopedic Consult paperwork because she had to do the 24-hour checks (reconciliation of past 24-hour physician's orders) anyway. Nurse #2 said that on 4/10/24, facility staff kept pressuring her to write a witness statement that indicated that she forgot to look at Resident #1's 03/18/24 orthopedic consult paperwork for any new orders. Nurse #2 said that the next day, on 04/11/24, she wrote another witness statement that detailed the events that occurred on 03/18/24 during her shift and gave it to a nurse manager at the facility. During an interview on 4/30/24 at 1:30 P.M., Nurse #1 (who was the overnight nurse on 03/18/24 into 03/19/24 and worked 10:00 P.M. to 6:00 A.M. and was assigned to Resident #1) said that she was not aware that Resident #1 had an orthopedic appointment the previous shift. Nurse #1 said that she was not aware that Resident #1 had an Orthopedic Consult on 3/18/24 until his/her 4/08/24 orthopedic appointment in which it was discovered that he/she had orders from the 3/18/24 appointment that were never implemented. Nurse #1 said that she did not get any report from the previous shift nurse (Nurse #2) that Resident #1 had been seen by the Orthopedic on 3/18/24. Nurse #1 said the only physician's orders that Resident #1 had prior to the 4/08/24 Orthopedic Consult was not to remove the right elbow splint, not to get the right elbow splint wet, monitor CSM and skin integrity (health of the skin). Nurse #1 said that after Resident #1 went to his/her 4/08/24 Orthopedic Follow-up Consult, she was told that he/she had recommendation orders from the 3/18/24 Orthopedic Consult that were never implemented and was told that Resident #1 had a Stage 4 pressure injury that was noted during the 4/08/24 Orthopedic visit. Review of Resident #1's Physician Interim Orders, dated 3/18/24 through 4/07/24, indicated there was no documentation to support that an order was obtained from the Physician regarding the recommendations from the Orthopedic PA related to his/her right elbow and transcribed onto his/her Treatment Administration Records (TAR). Review of Resident #1's TAR, dated 3/18/24 through 4/07/24, indicated there was no documentation to support Nursing removed his/her right arm splint and that the right elbow skin tear dressing was changed daily until healed. Further review of Resident #1's Medical Record, dated 3/18/24 through 4/07/24, indicated there were no Nursing Progress Notes with documentation to support Nursing removed his/her right arm splint and that the right elbow skin tear dressing was changed daily until healed. Review of Resident #1's Orthopedic Report of Consultation, dated 4/08/24, indicated he/she was seen for a healing displaced right olecranon fracture with noted pressure sore to his/her right elbow and had recommendations for the following: -Begin AROM and PROM to right elbow -Non-weight bearing to right elbow -Wound Clinic referral for right elbow pressure injury -Wound care for right elbow pressure injury: wet to dry dressing, change twice daily until seen by wound clinic -Follow-up with orthopedic in one week Review of Nurse Progress Note, dated 04/09/24, indicated that Resident #1's right elbow wound presented with purulent (thick discharge that usually implies an infection) substance, Nurse Practitioner (NP) was notified and Kelfex (antibiotic) 500 milligrams (mg) twice a day for 5 days was ordered. Review of Resident #1's Physician's Interim Telephone Order, dated 04/09/24, indicated to start Keflex 500 mg. twice a day, for 5 days. Review of a Physician Progress Note, dated 04/12/24, indicated that Resident #1 was currently on Keflex 500 mg. twice a day, monitor patient clinically and continue with medications as prescribed. Review of Resident #1's Orthopedic Report of Consultation, dated 4/15/24, indicated he/she was seen for a right olecranon fracture with a pressure injury present to his/her right elbow and had recommendations for the following: -AROM and PROM as tolerated -Wound Care for right elbow pressure injury: Continue wet to dry dressing and use Allevyn (foam dressing used to absorb wound exudate (drainage) dressing -Wound clinic referral and wound care per wound clinic physician -Follow-up with orthopedic in two weeks During a telephone interview on 5/06/24 at 8:40 A.M., the Orthopedic Physician Assistant (PA) said that Resident #1 was seen on 3/18/24 for a right elbow fracture. The Orthopedic PA said that Resident #1's right elbow was in a posterior splint, that a skin tear was noted, and he recommended that the splint be removed daily for AROM and PROM and for a dressing to be applied to the skin tear daily and a follow-up appointment was scheduled in 3 weeks. The Orthopedic PA said that there was no pressure injury noted to his/her right elbow at that time. The Orthopedic PA said that on 4/08/24, Resident #1 returned for his/her follow-up appointment, and it was discovered that he/she had a Stage 4 pressure injury to his/her right elbow. The Orthopedic PA said that he recommended that the splint be removed for AROM and PROM and he made recommendations for the treatment of the right elbow pressure injury which included a wound clinic consultation and a follow-up in 1 week. The Orthopedic PA said that on 4/15/24, Resident #1 returned for his/her follow-up appointment, and he made treatment changes to the right elbow pressure injury and recommended a wound clinic consultation and a follow-up appointment in 2 weeks. Review of Resident #1's Wound Clinic Report, dated 4/18/24, indicated that he/she was seen for a stage 4 pressure injury to his/her right elbow which measured 0.3 cm x 0.4 cm x 0.5 cm with undermining (erosion under the wound edges, resulting in a large wound with small opening), serosanguinous (containing both blood and serous fluid), exposed subcutaneous tissue and bone. The Report indicated that the pressure injury had a medium amount of necrotic (dead cells) tissue with a small amount of granulation (new connective tissue) and epithelialization (restoration of the damaged epithelium). The Report included recommendations for treatments and follow-up. During a telephone interview on 05/02/24 at 1:21 P.M., the Unit Manager said that Resident #1 had an orthopedic consultation on 03/18/24 that included recommendations that were not implemented. The Unit Manager said it was the responsibility of the nurse who was assigned to Resident #1 to review the consultation for any recommendations and to ensure that the recommendations were implemented. The Unit Manager said that she was not aware of any new recommendations that were made on the 03/18/24 orthopedic visit and said that she did not review Resident #1's 03/18/24 Orthopedic Consultation Report. The Unit Manager said that Resident #1 went for a follow-up orthopedic consultation on 04/08/24 and that was when she was made aware that he/she had developed a stage 4 pressure injury to his/her right elbow, and she was made aware that on 03/18/24 there were orthopedic consultation recommendations that were not implemented. The Unit Manager said that the facility did not have any specific policy and procedure on consultations. During an in-person interview on 04/30/24 at 2:35 P.M. and a follow-up telephone interview on 05/07/24 at 12:13 P.M., the Administrator said that Resident #1 was seen by the Orthopedic on 03/18/24 for his/her right elbow fracture, that recommendations were made and somehow the recommendations were missed and not implemented. The Administrator said that Resident #1 saw the Orthopedic again on 04/08/24 and it was discovered that he/she had developed a Stage 4 pressure injury to his/her right elbow. The Administrator said that it was his expectation that all consultations are reviewed by the nurse and the Unit Manager to ensure that any recommendation is implemented. The Administrator said it was the responsibility of the Unit Manager to follow up on all consultations to ensure that recommendations were implemented. On 04/30/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 04/08/24, Resident #1 was seen by the Orthopedic with new orders for daily dressing changes to right elbow stage 4 area, posterior splint with orders to remove splint for AROM and PROM, a follow-up Orthopedic Consultation and wound clinic consultation. B. On 4/08/24, the Facility developed a Policy and Procedure on the Clinical Protocol for diagnostic test results and consultations. C. On 04/08/24 and 04/12/24, the Staff Development Coordinator educated Licensed Nursing Staff on the new Policy and Procedure - Clinical Protocol for diagnostic test results, Consultations and notification of the physician of any new orders, reviewing consultation forms, transcribing any new orders and updating the facility physician with any new order recommendations. D. On 04/12/24, a whole house audit was conducted by the Unit Managers of all resident consultation appointments since January 2024 to verify that all recommendations were followed through on by Nursing. E. On 04/12/24, Resident #1's Plans of Care were reviewed and updated with interventions related to his/her right elbow wound interventions. F. On 04/15/24, Resident #1 was seen by Orthopedic, consultation recommendations were reviewed, physician was notified, and new orders were implemented. G. On 04/18/24, Resident #1 was seen at the Wound Clinic, recommendations were reviewed, physician was notified, and new orders were implemented. H. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Consultations, New Orders, Physician notification and Implementation of any new orders. I. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. J. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observations, record reviews, and interviews, the facility failed to ensure the nutritional status was maintained for one Resident (#49), out of a total sample of 19 residents. Specifically, the facility failed to address and implement the Dietitian's recommendations promptly, to provide supplements, to provide supervision and/or assistance during meals and assess his/her cognition secondary to mental status changes, in a timely manner, resulting in continued weight loss. Findings include: Resident #49 was admitted to the facility in October of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 6/14/21, indicated Resident #49 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. The MDS indicated the Resident required extensive assistance in transfers, dressing, bathing and eating, weight status at 146 pounds and height of 63 inches. Review of Resident #49's weight record indicated: - 5/07/21 - 144 pounds - 6/10/21 - 145 pounds - 7/09/21 - 133 pounds Review of the 7/10/21 Comprehensive Nutrition Assessment indicated Resident #49 weighed 133 pounds, was dependent and required assistance when he/she ate and drank. The assessment indicated both the Resident's physical and mental conditions affected his/her nutritional status, having had a surgery in June 2021. The assessment identified the Resident with a significant weight loss in 1 month, 12 pounds, 8 % in one month and a decline of 50% in his/her meal intake. At the time of the assessment, the Dietitian indicated Resident #49 had been delusional and is hallucinating - she questioned how this may be influencing the Resident's intake. The Dietitian considered the weight loss clinically significant and altered the plan of care. She recommended: - 120 milliliter (ml) house supplements, twice a day, - Increase supervision - assistance during meals - Assess the influence of his/her mood status is having on his/her intake - Important MD and Responsible representative be made aware. On 7/12/21, the weight record indicated a weight of 139 pounds. Review of the Dietitian's progress note, dated 7/12/21, indicated she was aware of the weight obtained on 7/12/21 of 139 pounds, a six pound gain. The Dietitian documented that the method of weighing the Resident had been inaccurate. The Dietitian documented the Resident's weight loss from June to July of 12 pounds in one month (8%) as significant and the Resident's intake had been declining. The Resident was eating only 50% of his/her meals. The Dietitian recommended nutritional supplements be started twice a day for added calories. Record review indicated the supplements were not initiated after the recommendations made on 7/10/21 and 7/12/21 and no additional weights were obtained to ascertain the accuracy of the weight obtained on 7/12/21. On 7/13/21, the Dietitian completed an Interdisciplinary Communication Form on 7/13/21 with the following recommendations: - 120 ml house supplements, twice a day, - Increase supervision - assistance during meals - Assess the influence of his/her mood status is having on his/her intake - Important MD and Responsible representative be made aware. Review of the clinical record failed to indicate the facility acted upon the recommendations, as there was no indication the Resident's Physician and responsible representative were notified of the significant weight loss and concerns associated with the weight loss, and the house supplements were not ordered. On 7/22/21, the weight record indicated the Resident was 133 pounds, a significant weight loss of 12 pounds from his/her June weight. On 7/27/21, the Dietitian completed a second Interdisciplinary Communication Form. The Dietitian identified Resident #49's significant weight loss and his/her decline in intake of 50% of his/her meals. The Dietitian documented that this was a second request and to start the supplements, to provide increased supervision at meals to prevent further weight loss and to notify the Physician and responsible representative. Review of the Nurse Practitioner (NP)'s progress note, dated 7/27/21, indicated the weight loss was addressed. The NP ordered the house supplements and requested staff to provide increased supervision at meals. Record review indicated the house supplements were not started until 8/2/21. The original recommendation was made on 7/13/21 and the second request was made on 7/27/21. There was no explanation for the delay in implementing the interventions. On 8/6/21, the weight record indicated Resident #49 weighed 131 pounds, a loss of two pounds, and indicated the Resident continued to lose weight. On 8/9/21, the Dietitian completed a third Interdisciplinary Communication Form. She identified Resident #49 having further weight loss and his/her intake remains less than 50%. She recommended super cereal for breakfast and to increase the house supplements from twice a day to three times a day. On 8/10/21 at 8:15 A.M., 8/10/21 at 12:15 P.M., on 8/11/21 at 12:00 P.M., on 8/16/21 at 8:10 A.M., on 8/17/21 at 11:50 P.M. and 8/18/21 at 12:30 P.M., the surveyor observed Resident #49 receive his/her meal in his/her room. On all days the Resident was in bed and staff brought the tray to the room, set the tray in front of the Resident and left the room. The surveyor did not observe the staff providing supervision and assistance as ordered by the Resident's Physician. On 8/10/21 at 12:15 P.M., the breakfast tray was left on the Resident's night table and in appearance the breakfast tray looked as if it had not been consumed much of it. The Resident was eating his/her lunch and said he/she did not like the meal. The Resident said he/she needed the staff, but could not reach the call light. The staff was notified of the Resident's request. Staff was not observed assisting with the Residents' meal. During an interview on 8/17/21 at 9:30 A.M., Certified Nursing Assistant (CNA) #3 and CNA #4 said the CNAs were updated on resident care such as feeding etc. with a care card. The care card provided them with a quick reference about specific resident care areas, such as feeding. The CNAs were unable to locate a care card for Resident #49 on the unit to use at the time of survey. Both CNAs said Resident #49 ate in his/her room and was a set up. Neither staff was aware of the need for supervision or assistance to prevent further weight loss. During an interview on 8/17/21 at 11:30 A.M., Unit Manager (UM) #2 said the Dietitian's recommendations were delayed and not implemented because they had been left in a folder. She said she found the recommendations in the folder and did not know why no one had addressed it sooner. UM #2 was unaware that the Resident was supposed to be supervised during meals to increase his/her intake or to be assessed for mental status changes.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure his/her safety was maintained to prevent an incident/accident with injury, when nursing staff applied a warm compress to his/her left neck area, did not go back to check on him/her, and as a result Resident #1 sustained a large burn to his/her left shoulder area requiring treatment with silver [MEDICATION NAME] (used to treat infections of second and third - degree burns) three times a day for 28 days. Findings include: The Policy titled, Applying Warm Compress, dated as revised February 2018, indicated that the purpose of the procedure was to ease the body of pain caused by inflammation and congestion, to promote drainage in infections and to improve circulation. The Policy indicated to check the resident's skin often for redness or discoloration and should you have reason to believe that the resident is being burned from the application to cease the treatment and summon the charge nurse at once. The Policy indicated to check the skin under the application every five minutes and if the skin appears red, remove the compress, cover the area with a towel and summon the charge nurse. The Policy indicated to apply the warm compress for 20 minutes. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired. Review of Facility report submitted via the Health Care Facility Reporting System (HCFRS) Report, dated 9/19/20, indicated that at 4:00 P.M., Resident #1 was administered a warm compress to his/her left lateral neck for an abscess which resulted in a burn. The Report indicated that the physician was notified and ordered silver [MEDICATION NAME] to the area and to cover with dry protective dressing and a cool compress. Review of the Facility's Internal Investigation Report, 09/19/20, indicated that a Certified Nurse Aide (CNA) found a towel on Resident #1's neck area, noticed that Resident #1 had a large wound on top of his/her left shoulder and reported this to the nurse. The Report indicated that the nurse found a large tear shaped wound on top of Resident #1's left shoulder with reddened areas noted up towards his/her ear. The Report indicated that the wound had a yellow base with red areas draining clear fluid. The Report indicated that the wound presented as a burn and that Resident #1 had received a warm compress to the area. Review of CNA #2's written witness statement, dated 9/19/20, indicated she (CNA #2) was washing Resident #1 when she noticed a red rash mark on the top of his/her left shoulder and when she removed his/her night gown, she saw a burn and notified the nurse. During an interview on 10/20/20 at 10:23 A.M., CNA #2 said while she was washing Resident #1, she noticed a gauze pad on his/her left shoulder that fell off during bathing. CNA #2 said that she noticed a reddish area with yellow mucous and pus on his/her shoulder that it looked like a burn. CNA #2 said that Resident had a cyst on the left side of his/her neck and said the nurses had applied warm compresses to that area. CNA #2 said she notified the nurse. Review of Resident #1's Nurse Progress Note, dated 9/19/20 as a late entry, indicated that she was notified by a CNA that Resident #1 had a large open area on top of his/her left shoulder. The Note indicated that she noted an open area on the top of Resident #1's left shoulder that was red with a yellow base draining clear drainage. The Note indicated she notified the physician and he ordered silver [MEDICATION NAME] with a dry protective dressing and a cold pack to be placed over the dry protective dressing to the area three times a day. During an interview on 11/3/20 at 10:42 A.M., Nurse #2 said that a CNA notified her that Resident #1 had a large wound on the top of her left shoulder. Nurse #2 said that she went to assess Resident #1 and noted a tear shaped wound on top of his/her left shoulder that was red from his/her left ear to the top of his/her left should with a yellow base draining clear fluid. Nurse #2 said that Resident #1 had received warm compresses in previous shifts to his/her left neck area and said the wound looked like a burn. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. (milligrams) one tablet by mouth three times a day. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's physician progress notes [REDACTED].#1 developed a skin abscess to his/her left neck, that on 9/14/20 warm compresses and Keflex 500 mg three times a day were ordered. The Note indicated that on 9/19/20, Resident #1 was noted to have a skin burn to his/her left shoulder and silver [MEDICATION NAME] and cool compresses were ordered. The Note indicated that the left shoulder appeared blistered today. During an interview on 10/19/20 at 12:25 P.M., the Nursing Supervisor said that nursing staff did not stay with Resident #1 during the application of the warm compress, that the warm compress was left on Resident #1 for too long, and said nursing staff did not follow the Facility's warm compress policy. During an interview on 11/05/20 at 1:04 P.M., the interim Director of Nurses (DON) said that Resident #1's burn was caused by the warm compress application to her left shoulder area, that it was her expectation that nursing staff follow the Facility's warm compress policy and said she was unsure if the nurse followed the Facility's policy or not.

Based on record review, and confirmed by staff interview, the Facility failed to ensure that the environment for two of six sampled residents (Resident #1 and Resident #2) remained as free of accident hazards as is possible: a) Resident #1 was positioned in the middle of the bed and not moved toward the staff member before turning Resident #1 away from the staff member, per facility positioning protocol, to ensure safe positioning. On [DATE] at approximately 6:15 P.M. the bed bolster (used as a positioning device to reduce the likelihood that a resident would roll off the bed) released from the weight of Resident #1 as CNA #1 attempted to reposition Resident #1 from the middle of the bed, and Resident #1 rolled out of bed onto the floor. The Health Care Proxy (HCP) Agent said Resident #1 died three days after the fall as a result of an intracranial hemorrhage that occurred when Resident #1 fell out of bed. b) Protocols were not in place for heating liguids in the microwave. On [DATE] Resident #2 sustained first degree burns (superficial burns in which damage was limited to the outer layer of the skin and was characterized by redness) and second degree burns (burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on the left upper arm when Resident #2 spilled hot tea on Resident #2's upper arm. Findings included: 1) The Facility Positioning policy indicated that residents were moved toward the staff member before turning a resident away from the staff member to ensure safe positioning in the bed. The Face Sheet indicated Resident #1 was admitted to the Facility, January, 2007, and had [DIAGNOSES REDACTED]. The Rehabilitation Program Director was interviewed at 2:30 P.M. on [DATE]. The Rehabilitation Program Director said, and the physical therapy (PT) evaluation, dated [DATE], indicated Resident #1 had decreased functional mobility and was evaluated for safe transfers. The Rehabilitation Program Director said, and the PT evaluation indicated Resident #1 remained totally dependent for positioning in bed. The PT discharge summary, dated [DATE], recommended a mechanical lift for transfers. The Director of Nurses (DON) was interviewed at 7:45 A.M. on [DATE]. The DON said, and the restraint assessment, dated [DATE], indicated siderails that were previously used as a positioning enabler were discontinued due to the frequency of bruising incidents, and bed bolsters were now used for positioning. The plan of care, updated [DATE], indicated Resident #1 required 1 nursing staff member to complete personal hygiene care and that bed bolsters were used for positioning. The DON said bed bolsters for positioning were used and assessed quarterly. The DON said, and the quarterly assessments, between November, 2010, and February, 2011, indicated that bed bolsters were used for positioning and there were no further incidents of bruising. The Significant Change Minimum Data Set (MDS) assessment, completed on [DATE], indicated that Resident #1 had a severely impaired cognitive status, had a short and long term memory problem, required assistance of one staff member for all personal hygiene needs, required extensive assistance by two or more staff members with bed mobility, was totally dependent for transfers, and received Hospice care. The Day Shift Certified Nurse Assistant (CNA) Coordinator was interviewed at 1:10 P.M. on [DATE]. The Day Shift CNA Coordinator said that the Day Shift CNA Coordinator was assigned to supervise staff and assist with residents personal care during the day shift. The Day Shift CNA Coordinator said that the Day Shift CNA Coordinator had changed Resident #1's bed linens and secured the bed bolsters to the bed during the day shift on [DATE]. Certified Nurse Assistant (CNA) #1 was interviewed at 2:20 P.M. on [DATE]. CNA #1 said CNA #1 was assigned to provide personal care to Resident #1 during the evening shift. CNA #1 said this was CNA #1's last day of orientation. The Evening Shift CNA Coordinator was interviewed at 2:00 P.M. on [DATE]. The Evening Shift CNA Coordinator said that Resident #1 was transferred into bed via the mechanical lift by two staff members shortly after 6:00 P.M. on [DATE]. The Evening Shift CNA Coordinator said the Evening Shift CNA Coordinator was assigned to supervise CNA #1 during the evening shift and had assisted with CNA #1's orientation to the Facility. CNA #1 said CNA #1 completed Resident #1's mechanical lift transfer into bed with the assistance of another staff member; CNA #1 said CNA #1 left Resident #1 in the middle of the bed, and as CNA #1 was washing Resident #1, CNA #1 rolled Resident #1 towards the right bed bolster, the bed bolster released from the weight of Resident #1, Resident #1 rolled out of bed onto the floor, and the Evening Shift Nurse #1 was summoned for help. CNA #1 said CNA #1 thought the bed bolster was properly attached to the bed. CNA #1 said CNA #1 thought Resident #1 would be safe being rolled towards the bed bolster because the bed bolster was attached and would prevent a fall. The Evening Shift Nurse #1 was interviewed at 6:40 A.M. on [DATE]. The Evening Shift Nurse #1 said on [DATE] at approximately 6:15 P.M. the Evening Shift Nurse #1 was called to Resident #1's room for an emergency. The Evening Shift Nurse #1 said the Evening Shift Nurse #1 found Resident #1 lying supine on the floor. The Evening Shift Nurse #1 said, and the Evening Shift Nurse #1's note indicated Resident #1 was alert and verbal, had an elevated blood pressure of ,[DATE], an elevated pulse of 90 beats per minute, and complained of left shoulder pain during the assessment. The Evening Shift Nurse #1 said, and the Evening Shift Nurse #1's note indicated Resident #1 had a hematoma on the left temporal lobe, a nickel size hematoma on the left shoulder, and a contusion on the left knee. The Evening Shift Nurse #1 said, and the Evening Shift Nurse #1's note indicated ice was applied to Resident #1's left forehead and the Telemedicine Physician said to transfer Resident #1 to the Hospital for evaluation. The Telemedicine physician note, dated [DATE], indicated Resident #1 had a significant extracranial hematoma and baseline dementia and recommended a hospital assessment. CNA #2 was interviewed at 9:50 A.M. on [DATE]. CNA #2 said CNA #2 was assigned to provide personal care to Resident #1 during the day shift and evening shift. CNA #3 was interviewed at 1:00 P.M. on [DATE]. CNA #3 said CNA #3 was assigned to provide personal care to Resident #1 from 6:00 A.M. to 2:00 P.M. CNA #2 and CNA #3 said, between [DATE] and [DATE], Resident #1 required the assistance of two staff members during transfers via a mechanical lift related to impaired mobility and required the assistance of one staff member for personal hygiene needs. The DON said the bolster was fastened properly during the day shift on [DATE]. The DON said Resident #1, on [DATE] at approximately 6:15 P.M., was not positioned toward CNA #1 per Facility policy, when Resident #1 was turned away from CNA #1 for personal care, per Facility policy. The DON said the DON believed Resident #1's injury occurred because Resident #1 had an unsafe position when rolled toward the bed bolster for personal care, the bed bolster released from the weight of Resident #1, and Resident #1 rolled out of bed onto the floor. The DON said CNA #1 was on the last day of orientation and had not been educated on bed bolsters. The DON said CNA #1 was since educated on bed bolsters. The DON said CNA #1 was counseled and re-educated on positioning because CNA #1 had not positioned Resident #1 toward CNA #1 when rolled toward the bed bolster, during personal care, per Facility policy. The Surveyor examined Resident #1's bed bolsters and they appeared in good working order. CNA #1 said CNA #1 thought Resident #1 would be safe being rolled towards the bed bolster because the bed bolster was secured in place and believed the bed bolster would prevent a fall. The DON said the bed bolsters would longer be used at the Facility due to the incident. The Health Care Proxy (HCP) Agent was interviewed by telephone at 12:45 P.M. on [DATE]. The HCP Agent said the Evening Shift Nurse #1 notified the HCP Agent on [DATE] at approximately 5:30 P.M. that Resident #1 rolled out of bed and was transferred to the Hospital for evaluation. The HCP Agent said the HCP Agent could not understand how Resident #1 could roll out of bed with bed bolsters in place and was concerned that possibly Resident #1 was dropped out of the mechanical lift. The HCP Agent said Resident #1 died three days after the fall as a result of a intracranial hemorrhage that occurred when Resident #1 fell out of bed on [DATE]. The Death Certificate, dated [DATE], indicated Resident #1 died from an intracranial hemorrhage due to a fall out of bed on [DATE]. 2) Resident #2 was admitted to the Facility November, 2009, and had a [DIAGNOSES REDACTED]. The Rehabilitation Program Director was interviewed at 2:30 P.M. on [DATE]. The Rehabilitation Program Director said, and the weekly rehabilitation progress note, dated [DATE], indicated that Resident #2 was able to feed self independently that included drinking hot beverages. The Rehabilitation Program Director said Resident #2 was observed eating and was able to eat and drink independently after set up. The Rehabilitation Program Director said Resident #2 was assessed after the incident and had no change in Resident #2's functional ability. Certified Nurse Assistant (CNA) #1 was interviewed at 4:45 P.M. on [DATE]. CNA #1 said CNA #1 was assigned to Resident #2's personal care needs during the night (10:00 P.M. on [DATE] to 6:00 A.M. on [DATE]). CNA #1 said Resident #2 requested a cup of tea and had a tea bag at the bed side. CNA #1 said CNA #1 left Resident #2's room to heat the tea in the microwave. CNA #1 said CNA #1 added water to the cup and heated the tea in the microwave for 90 seconds. CNA #1 said CNA #1 had not previously used the Facility microwave to heat liquids for residents. CNA #1 said Resident #2 was able to drink hot liquids independently from a cup. CNA #1 said after this CNA #1 heated Resident #2's tea for 90 seconds in the microwave, this CNA #1 placed the cup of tea on Resident #2's bedside table positioned next to Resident #2's bed, Resident #2 took several sips, and Resident #2 said that the tea was the way Resident #2 liked it. CNA #1 said CNA #1 did not think the tea was hot enough to burn Resident #2. CNA #1 said CNA #1 left the room to assist another resident and left work as scheduled at approximately 6:00 A.M. The Weekend Nursing Supervisor was interviewed at 8:00 A.M. on [DATE]. The Weekend Nursing Supervisor said at approximately 6:15 A.M. Resident #2 put the call light on for help because Resident #2 had spilled the tea on Resident #2's left upper arm, and the Weekend Nursing Supervisor immediately responded to assist Resident #2. The Weekend Nursing Supervisor said Resident #2 had spilled the tea on the left upper arm; Resident #2's johnny was removed, Resident #2's left upper arm was reddened, first aid was provided, and cool compresses were applied. The Director of Nurses (DON) was interviewed at 7:45 A.M. on [DATE]. The DON said, and the DON's internal investigation indicated that the DON interviewed CNA #1, and the DON's written statement, dated [DATE], indicated that CNA #1 said that: this CNA #1 heated Resident #2's tea for 90 seconds in the microwave, and this CNA #1 placed the cup of tea on Resident #2's bedside table. The DON said, and the DON's internal investigation indicated Resident #2 accidentally spilled the cup of tea and sustained a burn on Resident #2's left upper arm and the burn was described as a reddened area that had some blistered areas. The DON said, and the internal investigation indicated that Resident #2 accidentally spilled the cup of tea while seated in bed, the Weekend Nursing Supervisor immediately responded, first aid was given, the Physician was notified, and treatment orders were obtained. Unit Manager #1 was interviewed at 9:30 A.M. on [DATE]. Unit Manager #1 said this Unit Manager #1 was assigned to Resident #2's nursing care needs from 6:00 A.M. to 10:00 P.M. on [DATE]. This Unit Manager #1 said, and the nurse's note from 6:00 A.M. to 10:00 P.M., dated [DATE], indicated that Resident #2 spilled hot tea on Resident #2's left upper arm, the burn was described as a reddened blistered area, first aid was administered, the Physician was notified, and the Physician gave orders to cleanse the area with normal saline, and apply Silvadene (treatment of [REDACTED]. The DON said Resident #2 sustained a burn because the tea was heated in the microwave for 90 seconds, and unfortunately it was too hot. The DON said an internal investigation was started and the DON realized that prior to this incident there was no protocol for heating liquids in the microwave and staff had not been educated on safely heating liquids in the microwave. The DON said Resident #2 had no previous incidents of spilling hot liquids. The DON said that CNA #1 heated Resident #2's tea in the microwave for 90 seconds and placed the cup of tea on Resident #2's bedside table. The Telemedicine Physician Report, dated [DATE], indicated Resident #2 sustained a three inch diameter localized burn on the left upper arm that was described as closed blisters and that Resident #2 sustained a burn due to hot tea. The recommendations included Silvadene ointment daily and monitoring the temperature of the tea. The Wound Physician was interviewed at 9:40 A.M. on [DATE]. The Wound Physician said Resident #2 sustained a first degree burn (superficial burn in which damage was limited to the outer layer of the skin and was characterized by redness) and second degree burns (burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on the left upper arm due to hot tea and the burn on Resident #2's left upper arm was healing well. Resident #2 was interviewed at 12:30 P.M. on [DATE]. Resident #2 said Resident #2 accidentally spilled a cup of hot tea while in bed and sustained a burn on the left upper arm.