Every finding on record at Brandon Woods of New Bedford

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had reported to and been witnessed by a staff member to have been subjected to alleged physical and verbal abuse by two other staff members, the Facility failed to ensure staff consistently implemented and followed the Facility Abuse Policy, when staff members did not immediately report the allegation to their shift supervisor or the Administrator/designee as required. Findings include: Review of the Facility Policy titled Abuse Prevention Policies and Procedures, most recently revised 11/2024, indicated that it was the policy of the Facility for all staff upon observation of potential/alleged resident abuse, the observing staff is required to intervene, stop the potential/alleged abuse and report it to the supervisor. Review of Resident #1's clinical record indicated he/she was admitted to the Facility during September 2025 and his/her diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's most recent Minimum Data Set Assessment, dated 6/17/26, indicated his/her cognitive patterns were severely impaired and he/she was dependent on staff for assistance with bathing. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 6/08/26, indicated that the nursing supervisor reported to the Administrator that Helping Hand #1 reported that Resident #1 stated that two Certified Nurse Aides (later determined to be CNAs #1 and #2) gave him/her a cold shower and pulled his/her hair. During an interview on 7/15/26 at 10:35 A.M., Helping Hand #1 said that around 3:00 P.M. on 6/08/26, she heard Resident #1 screaming in the shower. Helping Hand #1 said that when she opened the shower room door, she saw CNA #1 showering Resident #1, and she heard Resident #1 stating in Spanish that the water was cold and that CNA #1 had pulled his/her hair. During an interview on 7/07/26 at 3:30 P.M., CNA #3 said that on 6/08/26 sometime between 3:00 P.M. and 4:00 P.M., Helping Hand #1 called for her to assist in the shower room. CNA #3 said that when she entered the shower room, Resident #1 was being showered by CNA #1 and CNA #2. CNA #3 said that Resident #1 was screaming and said that the water was cold. CNA #3 said that after she asked CNA #1 and CNA #2 to leave, Helping Hand #1 told her that Resident #1 had also alleged that CNA #1 had pulled his/her hair. Helping Hand #1 and CNA #3 said that they reported the alleged incident to the Nurse Supervisor around 7:00 P.M. on 6/08/26. During an interview on 7/10/26 at 11:55 A.M., the Nurse Supervisor said that around 7:00 P.M. on 6/08/26 Helping Hand #1 and CNA #3 told her about an incident they witnessed earlier during the shift in which Resident #1 alleged CNA #1 and CNA #2 showered him/her with cold water and pulled his/her hair. The Nurse Supervisor said that she asked Helping Hand #1 and CNA #3 the reason that they had not reported the allegation sooner and said they did not have an answer. During an interview on 7/07/26 at 3:50 P.M., the Administrator said that the Nurse Supervisor reported the allegation on 6/08/26 around 7:00 P.M., that CNA #1 and CNA #2 showered Resident #1 with cold water and pulled his/her hair, which was reported about three hours after the alleged incident had occurred. The Administrator said that as part of their investigation into the allegation, the Facility did not interview any other residents on the unit who had been cared for by CNA #1 and CNA #2 because the residents were alert, oriented and competent and he assumed they would have spoken up if they had experienced any issues with CNA #1 and CNA #2.

Based on record review and interview, the facility failed for one Resident (#106), in a sample of three closed records, to:-Establish and follow a written policy on permitting the Resident to return to the facility after being transferred to the hospital for evaluation; and -Through communication with the hospital, determine the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility and document why they could no longer meet those needs.Specifically, when Resident #106 was transferred to the hospital he/she was provided with a notice indicating he/she would have a bed hold. The following day, the facility informed the hospital that Resident #106 would not be allowed to return to the facility. Resident #106 has remained in the hospital (after 25 days) because he/she had nowhere to be discharged and had not been permitted to return to the facility. This has caused Resident #106 emotional distress. Findings include:Review of the Facility Assessment Tool, dated as revised in February 2026, indicated common diagnoses the facility would accept residents with or residents may develop, including Substance Use Disorder (SUD). Resident #106 was admitted to the facility in September 2025 with a diagnosis of history of SUD including alcohol and heroin. Review of the Minimum Data Set (MDS) assessment, dated 1/7/26, indicated Resident #106 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. The MDS indicated Resident #106 needed partial to moderate assist with activities of daily living (ADLs) and independently ambulated with a rolling walker. Review of the Care Plans indicated Resident #106 received assistance with ADLs, was at risk of falls and was at risk of complications related to cirrhosis. In addition, the care plans indicated Resident #106 had a history of SUD including heroin and was taking Suboxone (used to treat opioid use disorder) when admitted to the facility. A care plan update, dated 12/8/25, indicated the Suboxone had been discontinued. Review of the nursing progress notes, indicated on 3/1/26 Resident #106 was found using an illegal substance in his/her room and the police and Emergency Medical Services (EMS) were contacted. Resident #106 was transferred to the hospital at that time. The nursing progress note indicated the police recommended a No Trespass Order and one was initiated. During an interview on 3/26/26 at 3:13 P.M., Resident #106 said, They kicked me out. The Resident said he/she had used illegal substances and was sent to the hospital on 3/1/26. The Resident said the facility told the hospital that he/she was not allowed to return to the facility. He/she said the facility had gotten a No Trespass Order. The Resident said he/she did not think this was right and that he/she was now homeless. Resident #106 said the facility had been working with him/her on discharge planning and now had nowhere to go; he/she had been in the hospital since March 1st. The Resident said the facility would not take him/her back and now other facilities would not take him/her and believed the information about substance use was put out on the internet. The Resident said they were not provided with any paperwork regarding their right to appeal the discharge and did not know anything about this. The Resident said he/she had a problem with not being able to return to the facility, was depressed and added this is a lot. Review of Resident #106's paper and electronic medical record failed to include a No Trespass Order had been obtained. Review of the transfer paperwork included a Resident Notification Regarding Facility Bed Hold Notice and a 30-Day Notice of Intent to Transfer Resident, both dated 3/1/26. The 30-Day Notice of Intent to Transfer Resident form contained a section for Reasons for Discharge with multiple options, none of the reasons were checked off. There were no further notices in regard to discharge in the medical record or in the Medical Record office. During an interview on 3/26/26 at 4:28 P.M., Social Worker #1 said the two notices provided to the surveyor dated 3/1/26 were sent when the Resident transferred to the hospital. She said the facility had determined Resident #106 was not allowed to return to the facility due to illegal substance use and she was not involved in any discharge notices being provided to the Resident when this determination was made. She said the Resident had previously been referred to Elder Services for help with returning to the community and had been working on transitional services prior to the hospital transfer as the Resident did not have a place to discharge to. Review of the nursing progress notes indicated on 11/6/25 a nurse reached out to a family member of Resident #106 and was notified the Resident had no where to live. Review of the Social Service progress notes indicated Resident #106 had been referred to Elder Services in November 2025 to assist with returning to the community. The Social Service progress note on 2/9/26 and 2/16/26 indicated Resident #106 continued to work with Elder Services on transitioning to the community. During an interview on 3/26/26 at 4:49 P.M., the Administrator said on 3/1/26 the staff had found Resident #106 with an illegal substance and the Resident was transferred to the hospital. He said the interdisciplinary team met on 3/2/26 and determined the Resident could not return to the facility based on the use of illegal substances. The Administrator said he thought the original notices sent with the Resident on 3/1/26 were the correct Intent to Discharge form and no one sent any additional notices after the team discussion to not allow the Resident to return on 3/2/26. He said the facility had not pursued a No Trespass Order and there was no legal reason to prevent the Resident from returning to the facility. The Administrator said the facility was not a good fit for the Resident because of the substance use. He said there had been no updated clinical information provided from the hospital to indicate changes to the clinical care of the Resident. He said the facility felt that based on the Resident's substance use the Resident needed more help than a nursing home. He said the facility knew Resident #106 had a history of SUD prior to the original admission. He said the facility did not have a SUD counselor but did have the ability to coordinate services through their iPad and had provided this to other residents in the past. He said he was not sure if this had ever been offered to Resident #106. He said the facility did not have any knowledge of illegal substance use during the Residents stay at the facility from September 2025 through 2/28/26. Review of the Behavioral Health Group progress note from the Psychiatric Nurse Practitioner (11/19/25) and Licensed Independent Clinical Social Worker (11/26/25, 12/26/25, 2/6/26) failed to indicate Resident #106 was receiving counseling for SUD. During an interview on 3/26/26 at 5:19 P.M., the Admissions Coordinator said the process was for the hospital and facility to communicate through the Admissions Coordinators. She said any clinical updates from the hospital would have been uploaded in the electronic medical record and confirmed no clinical updates had been received from the hospital for Resident #106. She said the hospital Emergency Department had reached out at the beginning of March 2026 regarding the Resident returning to the facility and the Admissions Department had informed the hospital that the facility would not be allowing Resident #106 to return to the facility. She said this was why there were no additional updates on the Resident. She said this was a verbal communication and the Admissions Department did not send any written notice of discharge. During an interview on 3/27/26 at 1:23 P.M., the Administrator said he reviewed the policies himself and with the clinical corporate consultant and there was no policy regarding permitting residents to return to the facility following hospitalization. Review of the medical record failed to indicate why the facility could no longer care for the Resident. Refer to F628

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Monitor the dishwasher sanitation chemical agent after switching from high temperature dishwasher to chemical sanitation for 43 days to ensure all dishes were properly sanitized to prevent food borne illnesses; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) and ensure glove use was limited to a single task. Findings include: 1. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:-4-302.14 Sanitizing Solutions, Testing Devices. Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic.-4-501.114 Machine Washing and Sanitizing - Dishwashing machines use either heat or chemical sanitization methods. Manufacturers' instructions must always be followed. Review of the Manufacturer's directions for the sanitizer used in the facility indicated test procedures were as follows:-Chlorine sanitizer test for low temp dish machines.-Remove a 1.5-inch strip of clean, dry test paper from container below.-At the end of the rinse cycle, dip strip of test paper into the final rinse water from the dish machine. Chlorine papers are dip, blot and read at once.-Immediately compare test paper strip to color chart on the test strip dispenser. Test results may be in the range below.-Test paper reading: Chlorine. 50-100 parts per million (ppm)-Rinse water temperature 120 or above. Review of dishwasher Maintenance Invoice, dated 2/9/26, indicated the work requested for the main kitchen dishwasher was, a chemical dispenser needs to be switched to a bleach sanitizer. The water temperature is not hot enough. During an interview on 3/24/26 at 8:05 A.M., the Food Service Manager (FSM) said the dishwasher booster went last week. During an interview on 3/26/26 at 10:04 A.M., the FSM said he has not been testing the sanitizer level in the dishwasher since they switched over. The FSM said the contractor switched them over to the chemical sanitizer and said he was all set. The FSM said he could call the contractor to have the sanitizing solution tested. During an interview on 3/26/26 at 4:55 P.M., the FSM said the Consultant Service Contractor (CSC) just told him that he must test the dishwasher sanitizer level, and the chlorine level is supposed to be at 50 ppm. The FSM said now that he knows that he will educate the staff on testing the Chlorine sanitizer levels. The FSM said the CSC told him the chemical sanitation level was a little low and provided him with testing instructions. During an interview on 3/26/26 at 5:00 P.M., the CSC said he tested the sanitizer level, and it was trace (too low) as the test strip barely changed color. The CSC said the sanitizer level for low temperature dish machines should have a chlorine level of 50 ppm for this machine. 2. Review of the 2022 Food Code by the U.S. FDA, revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 3/24/26 at 8:05 A.M., the surveyor observed [NAME] #1 during breakfast tray line service and made the following observations:-Cook #1 was wearing a pair of gloves and plating food on the tray line. -Cook #1 left the tray line, turned the stove on and with her gloved hands, cracked two pasteurized eggs in a frying pan, then returned to the tray line. [NAME] #1 did not change her gloves and continued to plate breakfast items and touch the utensils. -Cook #1 while plating food and wearing the same gloves, turned multiple times to open the oven and to retrieve a croissant with her gloved hands and place the croissant on a resident's plate. -Cook #1 finished cooking the eggs, turned off the stove and returned to plating food wearing the same gloves. -Cook #1 for the second time, turned and cracked two more pasteurized eggs in the frying pan, still wearing the same gloves, and returned to the tray line continuing to plate breakfast items. During an interview on 3/24/26 at 8:25 A.M., the FSM said [NAME] #1 should be changing her gloves when she leaves the workstation and before handling the croissants.

Based on records reviewed and interviews, the facility failed to ensure staff maintained complete and accurate medical records for five Residents (#7, #42, #9, #14, and #4), out of a total sample of 21 residents. Specifically, the facility failed to:1. For Resident #7, ensure physician and nurse practitioner progress notes were accessible in the Resident's medical record; and2. For Resident #42, ensure physician and nurse practitioner progress notes were accessible in the Resident's medical record; and3.For Resident #9, ensure primary physician progress notes were accessible in the Resident's medical record; and4. For Resident #14, ensure primary physician and wound nurse practitioner progress notes were accessible in the Resident's medical record; and5. For Resident #4, ensure his/her monthly behavior sheets were complete and accurate. Review of the facility's policy titled Medical Records Procedure, dated as revised in December 2025 indicated the following should be retained in the medical record:-1 year of physician progress notes-last 6 months of consults 1. Resident #7 was admitted to the facility in February 2026. On 3/24/26 and 3/25/26, the surveyor reviewed the Resident's paper and electronic medical records and was unable to locate any physician or nurse practitioner progress notes. On 3/25/26 at 4:10 P.M., the Director of Nursing (DON) provided the surveyor with progress notes dated 2/10/26, 2/11/26, and 2/27/26, and 3/6/26 from the medical records office that had not been filed in the Resident's medical record. 2. Resident #42 was admitted to the facility in February 2026. On 3/24/26 and 3/25/26, the surveyor reviewed the Resident's paper and electronic medical records and was unable to locate any physician or nurse practitioner progress notes. On 3/25/26 at 4:10 P.M., the DON provided the surveyor with progress notes, dated 2/10/26, 2/11/26, and 3/17/26, from the medical records office that had not been filed in the Resident's medical record. 3. Resident #9 admitted to the facility in May 2025. Review of the paper and electronic medical record for Resident #9 only included progress notes from the NP, there were no progress notes from the Primary Physician. During an interview on 3/25/26 at 4:10 P.M., the DON said Resident #9 had been seen by their Primary Physician and she would need to call them to request the documentation. On 3/25/26 at 5:20 P.M., the surveyor was provided with Primary Physician visits from 5/2/25, 7/1/25, 8/30/25, 10/29/25, 12/28/25 and 2/26/26. During an interview on 3/25/26 at 5:20 P.M., the DON said the Primary Physician had sent over the years' worth of visits and they had not been in the medical record prior. 4. Resident #14 was admitted to the facility in April 2022. Review of the paper and electronic medical record for Resident #14 only included progress notes from the NP, there were no progress notes from the Primary Physician. On 3/26/26 at 12:50 P.M., the surveyor was provided with Primary Physician visits from 2/3/25, 4/7/25, 6/2/25, 8/4/25, 10/6/25, 12/1/25, and 2/9/26. During an interview on 3/26/26 at 12:50 P.M., the DON said the Primary Physician for Resident #14 had sent over a years' worth of visits that were not in the medical record. During an interview on 3/26/26 at 1:07 P.M., the Medical Records staff said the process for physician visits was that she received the physician visits from the physicians (MDs and NPs) and uploads them to the electronic medical record. She said she would not have noticed if a physician had not been sending over visits as she was not responsible for tracking visits and thought the MDs only had to see the residents once per year, so she would not have noticed if the visits she received were only from the NPs. She said she started uploading physician visits to the electronic medical record in 2026 and was behind on uploading them. Review of the medical record indicated Resident #14 had a pressure ulcer and was seen by a Wound NP. Review of the medical record indicated the last documentation of a visit with the Wound NP was 12/22/25. During an interview on 3/26/26 at 12:50 P.M., the DON said she receives the Wound NP Progress notes from the consultant, makes any recommended changes and then sends the progress notes over to the Unit Managers to put in the medical record. During an interview on 3/26/26 at 2:03 P.M., Unit Manager #2 said she receives the Wound NP Progress notes and then leaves them for the Primary Physician or NP to review and sign. She said she was not sure who was responsible for putting them in the medical record after that. 5. Resident #4 was admitted to the facility in April 2025 with diagnoses which included mood disorder, depression, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 3/22/26, indicated Resident #4 displayed wandering behaviors on one to three days during the assessments look back period. Further Review of the MDS assessment indicated he/she received antipsychotic medication during the look back period. Review of Resident #4's Physician's Orders indicated but was not limited to: -Clozapine (antipsychotic) 50 milligrams (mg) every 12 hours, dated 4/30/25 Review of Resident #4's February 2026 and March 2026 Medication Administration Records (MAR) indicated he/she received Clozapine as ordered. Review of Resident #4's February 2026 monthly behavior sheets, on 3/25/26, indicated the Resident should be monitored each shift for hypersexual behaviors, depressed behaviors, and anxiety. Further review of Resident #4's February 2026 monthly behavior sheets indicated the facility failed to the document the presence or absence of behaviors as evidenced by 77 out of 84 opportunities left blank and were incomplete. Review of Resident #4's March 2026 monthly behavior sheets, on 3/25/26, indicated the Resident should be monitored each shift for hypersexual behaviors, withdrawn/depressed behaviors, and resistance to care. Further review of Resident #4's March 2026 monthly behavior sheets indicated the facility failed to the document the presence or absence of as evidenced by 68 out of 72 opportunities left blank and were incomplete. During an interview on 3/26/26 at 1:52 P.M., Nurse #5 said residents on medications used to manage behaviors required a monthly behavior sheet. Nurse #5 said nursing should document the number of identified behaviors every shift. Nurse #5 said if there were no behaviors the nurses should document a zero for accurate monitoring and to show that interventions were working. During an interview on 3/26/26 at 3:03 P.M., the DON said nurses should be completing the behavior sheets at the end of every shift.

Based on observations, interviews, and record reviews, the facility failed to ensure one of one sampled resident with a pressure ulcer (Resident #14), out of a total sample of 21 residents, was provided accurate interventions and treatments to promote healing. Specifically, for Resident #14, the facility failed to:a. Set the air mattress per the physician's orders; andb. Ensure treatments for a left heel pressure ulcer were documented and consistent with current physician's orders. Findings include:Resident #14 was admitted to the facility in April 2022 with a diagnosis of advanced dementia and was receiving hospice services. Review of the Minimum Data Set (MDS) assessment, dated 1/28/26, indicated Resident #14 had long-term and short-term memory problems, was dependent on staff for care, had one stage 3 (full thickness loss of skin) pressure ulcer, had a pressure reducing device on the bed, and received pressure ulcer/injury care. Review of the Care Plans indicated Resident #14 was at risk for skin breakdown and had active pressure ulcers with interventions including: an air mattress and providing treatments as ordered a. On 3/24/26 at 8:28 A.M., the surveyor observed Resident #14 lying on an air mattress. The air mattress was set above 320 pounds. During an interview on 3/24/26 at 12:04 P.M., the Family Member of Resident #14 said the Resident had developed a new pressure ulcer on their buttocks this past week and she had requested that Resident #14 not get out of bed to avoid increased pressure while sitting in the wheelchair. She said she would rather have the staff reposition the Resident on the air mattress to alleviate the pressure. Review of the Wound Nurse Practitioner's (NP) Progress Note, dated 3/23/26, indicated Resident #14 had developed a new stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right buttock. The assessment/plan indicated to use the pressure redistribution mattress per facility protocol. Review of the Physician's Orders included an order to monitor that the air mattress was set to 175-pound weight every shift. The surveyor observed the air mattress set over 320 pounds on the following days: -3/25/26 at 11:09 A.M. -3/25/26 at 3:15 P.M.-3/26/26 at 8:00 A.M. Review of the Treatment Administration Record (TAR) indicated the nurse signed off that the air mattress was set to 175 pounds on 3/24/26, 3/25/26 and 3/26/26. During an interview on 3/26/26 at 12:50 P.M., the Director of Nurses (DON) said the air mattress for Resident #14 should be set at his/her weight as indicated on the order. She said the air mattress should not be set at over 320 pounds. During an interview on 3/26/26 at 2:10 P.M., Unit Manager #2 said the air mattress should have been checked every shift as indicated on the order and set to the correct settings. b. Review of the medical record indicated Resident #14 had developed a stage 3 pressure ulcer to the left heel in December 2024. Review of the Wound NP's Progress Note, dated 2/9/26, included a recommendation to change the left heel treatment to an antimicrobial cleanser, followed by Calcium Alginate, to secure with an ABD pad (gauze pad) and then rolled gauze. Review of the Physician's Orders indicated the treatment to the left heel was changed as recommended on 2/9/26. Review of the TAR indicated there was no assigned time to administer the new treatment and there was no documentation to indicate the treatment was completed from 2/10/26 through 2/15/26. Review of the Wound NP's Progress Note, dated 2/16/26, included a recommendation to change the left heel treatment to cleanse with wound cleanser, followed by anasept gel (a gel designed to maintain a moist wound environment that promotes healing while providing broad-spectrum antimicrobial activity), followed by an ABD pad and then a gauze roll. Review of the TAR indicated there was no assigned time to administer the new treatment and there was no documentation to indicate the treatment was completed from 2/17/26 through 3/22/26 when the treatment was changed again. Review of nursing notes under treatments indicated a treatment to the left heel was completed on 2/10/26 and 2/17/26 but failed to indicate which treatment was provided. During an interview on 3/26/26 at 10:02 A.M., Nurse #3 said she frequently works on the unit where the Resident resides but was not always assigned to Resident #14. She said she had last worked on that assignment about two weeks prior. She said she knew that the Resident received treatments to the left heel daily but could not be sure which treatments were completed. She reviewed the medical record and could not say where it would be documented which treatment was provided if it was not on the TAR. Review of the medical record indicated Nurse #3 provided care to Resident #14 on 2/20/26, 2/27/26, 3/3/26, 3/6/26, 3/7/26, 3/10/26, and 3/13/26. During an interview on 3/26/26 at 2:10 P.M., Unit Manager #2 said the treatment changes on 2/9/26 and 2/16/26 were not entered into the electronic medical record correctly and were not showing up for the nurses to be informed of what the treatment was and to sign off that the treatment was complete. She said the nurses were completing treatments every day to the left heel, but she couldn't be sure of what the treatment was since there were two changes in February. During an interview on 3/27/26 at 10:41 A.M., Nurse #7 said she worked on the unit every weekend. She said the top of the electronic medication treatment page would tell the staff which treatment to complete. Review of the page with the surveyor failed to indicate the current treatment order for Resident #14. She said she was not sure how some treatments were listed at the top of the page and others were not. She said she had completed a treatment for Resident #14 on the weekends, and it was the treatment with the ABD pad. She said she could not remember which treatment with the ABD pad, as both recent treatments included an ABD pad. During an interview on 3/26/26 at 12:50 P.M., the DON said the staff had been working very hard to get the heel wound healed and had been doing treatments daily. She said, based on the medical record there was no way to tell which treatment was being provided to the Resident. She said both treatment orders should have had an assigned shift to provide the treatment to allow the staff to see the correct treatment and sign off.

Based on interviews and record review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#32) with a history of trauma, out of a total sample of 21 residents. Findings include:Review of the facility's policy titled Primary Care Post-Traumatic Stress Disorder (PC- PTSD-5) Screen Assessment Procedure, dated 1/2024, included but was not limited to:-The PC- PTSD-5 screen is a five item screen designed to identify individuals with probable PTSD. Those screening positive require further assessment, preferably with a structured interview, and care planning.-Procedure:a. To be completed by Social Services or clinical designee on admission and annually thereafterb. If the respondent indicates a trauma history - experiencing a traumatic event over the course of their life the respondent is instructed to answer five additional yes/no questions about how that trauma has affected them over the past monthc. If there are any yes responses, care plan goals and interventions must be in place to address experiences and preferences in order to eliminate or mitigate triggers. Resident #32 was admitted to the facility in March 2026 with diagnoses which included PTSD (a mental health condition triggered by witnessing or experiencing terrifying events, causing long-lasting, severe distress). Review of Resident #32's Social History Assessment, dated 3/10/26, failed to identify a history of a traumatic event. Further review of the medical record failed to indicate that a PTSD Screen/Assessment was completed. Review of Resident #32's care plans failed to indicate he/she had a history of a traumatic event. Review of the Behavior Health Group, Medication Management visit notes, dated 3/17/26 and 3/24/26, indicated Resident #32 had a medical history that included PTSD. Review of the Behavior Health Group Therapy visit note, dated 3/20/26, indicated Resident #32 had a medical history that included PTSD and he/she discussed some personal history, including trauma he/she had experienced in his/her life. Further review of the Behavior Health Group visit notes failed to indicate potential triggers for Resident #32. During an interview on 3/26/26 at 8:47 A.M., Nurse #5 said she does not know about Resident #32's PTSD, previous trauma, or triggers. Nurse #5 reviewed Resident #32's medical record and said there was no assessment related to his/her history of trauma. During an interview on 3/26/26 at 1:18 P.M., Social Worker #1 said Resident #32 had a history of PTSD. Social Worker #1 reviewed Resident #32's medical record and said the PTSD Assessment should have been completed on admission, and a care plan should have been developed for PTSD. Social Worker #1 said the assessment and care plan should have been completed to identify potential triggers and to prevent potential re-traumatization. During an interview on 3/26/26 at 3:03 P.M., the Director of Nurses said nursing did not complete an assessment for PTSD, but a resident-specific care plan should be developed.

Based on record review and staff interview, the facility failed to ensure the Resident Representative (guardian) was not extended authority of decision making beyond the extent required by the court to consent to the administration of an antipsychotic medication for one Resident (#81), from a total sample of 21 residents. Specifically, the court approved Treatment Plan allowed Resident #81 to be treated with Seroquel and Rexulti (antipsychotics) and the Resident Representative consented for Resident #81 to be administered Zyprexa, which was not an approved antipsychotic medication on the Treatment Plan. Findings include:An Incapacitated Person (I.P.) is someone who is determined by the Court to have a clinically diagnosed condition that leaves them unable to make or communicate decisions affecting their physical health, safety, or self-care. The Guardian appointed by the court for an I.P. will make some or all decisions for the I.P. If the I.P. requires medical treatments or care that the court considers extraordinary, a guardian must obtain the Court's permission before authorizing the treatment. At a [NAME] guardianship hearing, the Court is asked to authorize extraordinary medical treatment for an Incapacitated Person. This usually refers to treatment with antipsychotic medication. Resident #81 was admitted to the facility in January 2024 with a diagnosis of dementia with behavioral disturbance. Review of the medical record indicated Resident #81 had a family member appointed as their permanent legal guardian and a Treatment Plan for the use of antipsychotics was implemented. Review of the court approved Treatment Plan for Resident #81 indicated in July 2025 the approved antipsychotic medications included Seroquel and Rexulti. Review of the Behavioral Health Group progress notes indicated on 8/19/26 the Psychiatric Nurse Practitioner recommended to discontinue Seroquel and to start Zyprexa (Olanzapine) 5 milligrams (mg) twice daily. Review of the Informed Consent for Psychotropic Administration form indicated the guardian of Resident #81 consented to the use of Zyprexa on 10/9/25. Review of the medical record included an order to start Zyprexa 5 mg twice daily on 10/10/25. On 11/25/25, the Zyprexa increased to 7.5 mg twice daily. Review of the medical record, including progress notes, failed to indicate the facility had submitted any documentation to the court to change the Treatment Plan to include Zyprexa. During an interview on 3/27/26 at 2:50 P.M., Social Worker #2 said Zyprexa was not listed on the court approved Treatment Plan and the court approved Treatment Plan should be followed. She said she had contacted the facility attorney, and the facility will submit to the court for an amendment to the Treatment Plan. She said, prior to the surveyor inquiry, the facility had not requested an amendment to the Treatment Plan to include the antipsychotic medication that was being administered outside of the Treatment Plan.

Based on observation, interview, and document review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to properly secure Xanax (a controlled substance prescribed for anxiety and panic disorders) for one Resident (#44), out of a total sample of 21 residents.Findings include: Review of the facility's policy titled Medication Labeling and Storing, undated, indicated but was not limited to the following:-Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following:-Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision-making capacity to do so safely.Resident #44 was admitted to the facility in July 2025 with diagnoses including anxiety and panic disorder.Review of the Minimum Data Set (MDS) assessment, dated 1/21/26, indicated Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.Review of Resident #44's Self-Administration Medication assessment, dated 7/28/25, indicated he/she was not capable of self-administering his/her medications. Review of Resident #44's Physician's Orders included but were not limited to:-2/16/26: Xanax 0.25 milligrams (mg) tablet daily as needed.On 3/24/26 at 9:25 A.M., the surveyor observed Resident #44 in bed with a plastic medication cup on his/her nightstand containing a white oval tablet. During an interview on 3/24/26 at 9:26 A.M., Resident #44 said that the white oval tablet was Xanax. During an interview on 3/24/26 at 9:30 A.M., Nurse #1 said she was unsure if Resident #44 was cleared to self-administer medications. Nurse #1 retrieved the white tablet from Resident #44's room and confirmed the white oval tablet was Xanax. Nurse #1 said she was unsure how long the tablet had been in Resident #44's room.During an interview on 3/24/26 at 9:35 A.M., Unit Manager #1 (UM) said Resident #44 was not cleared to self- administer medications. UM #1 reviewed the first-floor unit narcotic book and said the last time Xanax was signed out to Resident #44 was on 3/17/26. During an interview on 3/24/26 at 2:19 P.M., UM #1 said she had confirmed the medication was last administered to Resident #44 on 3/17/26 and that Resident #44 told her he/she had been keeping it in a drawer. Review of the first-floor unit narcotic book on 3/24/26 at 2:40 P.M., indicated for Resident #44 that Xanax one 0.25 mg tablet was signed out on 3/17/26 at 10:24 A.M. During an interview on 3/25/26 at 11:25 A.M., Resident #44 said that he/she had the Xanax tablet since some time last week. Resident said he/she had requested the tablet, and he/she had saved it because the last time he/she had needed the Xanax it took several hours for the nurse to dispense it. Resident #44 said he/she wanted to make sure to have one on hand if needed again.During an interview on 3/25/26 at 12:10 P.M., the Director of Nursing (DON) said that it would be her expectation that the nurses stay with the residents until they finish taking their medications as this is best nursing practice.

Based on interview and record review, the facility failed to ensure the Resident's Health Care Proxy (HCP, individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications) about changes in their condition and potential need to alter the treatment plan for one Resident (#6), from a total sample of 21 residents. Specifically, the facility failed to notify the HCP of a change in the Resident's condition requiring transfer to the hospital and a significant weight loss.Findings include:Review of the facility's policy titled Resident Change in Condition, reviewed February 2024, indicated but was not limited to:-To facilitate nursing response for residents exhibiting change in condition.-The resident's Physician, legal representative and/or responsible party is to be notified.Review of the facility's policy titled Resident Nutritional Policy and Procedure, reviewed June 2025, indicated but was not limited to:-Weight Monitoring: -If a significant weight loss occurs, defined as five percent (5%) in one month, seven- and one-half percent (7.5%) in three months, or ten percent (10%) six months. -Ensure the family/next of kin/responsible party is notified regarding the significant change.Resident #6 was admitted to the facility in April 2025 with diagnoses including anoxic brain injury (occurs when the brain is completely deprived of oxygen, causing cell death within minutes) and quadriplegia (paralysis caused by illness or injury to the brain or spinal cord (typically C1-C8 vertebrae), resulting in partial or total loss of function in all four limbs and the torso).Review of the Minimum Data Set (MDS) assessment, dated 3/11/26, indicated Resident #6 had a moderate cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Further review of Resident #6's MDS indicated he/she had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months not prescribed by the physician and his/her HCP was activated.Review of Resident #6's medical record indicated he/she had cognitive impairment, and his/her HCP was invoked on 1/6/26.During a telephonic interview on 3/24/26 at 3:14 P.M., the HCP said the last time Resident #6 was transferred to the hospital the facility did not notify them and they were notified by the social worker from the hospital. The HCP said she was not aware of Resident #6 having a weight loss and they did not think Resident #6 had a weight loss.a. Review of Resident #6's medical record indicated he/she was transferred to the hospital for a change in condition.Review of Resident #6's Nursing Note, dated as late entry for 1/29/26, indicated but was not limited to:-Resident not feeling well this shift. Resident was lethargic and not being able to voice their needs when asked a question. Resident would just mumble their words. Resident did not eat breakfast this morning. This Nurse (#4) called the Nurse Practitioner and was told to send the Resident to the hospital. Resident was transferred to the hospital.Review of the Nursing Home to Hospital Transfer Form and the Situation-Background-Assessment-Recommendation (SBAR) Communication Form, undated, indicated but was not limited to:-Change in condition, symptoms, or signs observed and evaluated is/are: Lethargic and dark urine-This started on: 1/27/26-Since this started, symptoms have gotten worse.-The following sections were left blank: Contact Person, relationship to resident, contact information, notified of transfer, and they are aware of clinical situationThe SBAR form failed to indicate the HCP was notified of the transfer.During an interview on 3/26/26 at 9:31 A.M, Nurse #4 said when a resident needs to be sent to the hospital the HCP must be notified of the transfer and documented on the hospital transfer forms and in the medical record. Nurse #4 reviewed the undated Nursing Home to Hospital Transfer Form and the SBAR Communication Form and the nurse's note, dated as late entry for 1/29/26. She said she completed the Nursing Home to Hospital Transfer Form and the SBAR Communication Form for Resident #6 on 1/26/26 and wrote the nursing note, dated 1/29/26, she did not document if she notified Resident #6's HCP of his/her transfer to the hospital.During an interview on 3/26/26 at 1:10 P.M., the Director of Nursing (DON) said anytime a resident was sent to the hospital the HCP must be notified and it must be documented in the medical record. She said if it was not documented then there was no way to ensure they were notified.b. Review of Resident #6's Dietitian's notes indicated but was not limited to:-1/7/26 Weight loss significant. See assessment.-1/23/26 Resident with visible weight losses. Reviewed with nursing.Review of the Nutrition Assessment, dated 2/26/26, indicated but was not limited to:-Percent of weight loss: -6.6% in one month -16% in three monthsFurther review of Resident #6's medical record failed to indicate his/her HCP was notified of his/her significant weight loss.During an interview on 3/26/26 at 9:31 A.M, Nurse #4 reviewed Resident #6's medical record and said once a weight loss was identified, the Dietitian would write recommendations, and then nursing would call the Physician/ Nurse Practitioner and call the HCP to notify them of a significant weight change. She said nursing was responsible for notifying the HCP. She said she did not see any documentation of Resident #6's weight loss notification. During a telephone interview on 3/26/26 at 12:39 P.M., the Dietitian said Resident #6 had a significant weight loss. She said when a weight loss was identified she would make recommendations and update the care plan. She said nursing was responsible for notifying the HCP.During an interview on 3/26/26 at 1:10 P.M., the DON said weight loss was reviewed daily in morning meeting, and weekly at the facility's risk meeting. She said the Dietitian would make recommendations, but it was nursing's responsibility to notify the Resident's HCP and the notification must be documented in the medical record.

Based on interview and record review, the facility failed for one Resident (#106), out of three closed records reviewed, to provide in writing, the reason for discharge to the Resident, and failed to send a copy of the notice to the Ombudsman office. Specifically, after transferring Resident #106 to the hospital, the facility determined they would not allow the Resident to return from the hospital and did not send any written notices to the Resident or the Ombudsman. Resident #106 remained in the hospital as of 3/26/26. Findings include:Review of the facility's policy titled Notification of Transfer/Discharge and Bed Hold, revised in December 2025, indicated the following:-When the transfer/discharge of a resident occurs to the hospital, the Social Worker is to complete a Notice of Intent to Transfer Resident with Less than 30 Days' Notice or 30-Day Notice of Intent to Transfer Resident, these are facility specific, and send it along with the Facility Bed Hold Policy and Resident Notification Regarding Facility Bed Hold cover letter, with the resident to the hospital- When the discharge of a resident occurs due to a discharge home, a discharge for nonpayment, the Social Worker is to complete a Notice of Intent to Discharge Resident with Less than 30 Days' Notice (Expedited Appeal) or Notice of Intent to Discharge Resident. The notice is to be issued prior to the discharge or on the next business day following the discharge. A note must be made in the social service section of the chart. Resident #106 was admitted to the facility in September 2025 with a diagnosis of history of substance use disorder (SUD) including alcohol and heroin. Review of the Minimum Data Set (MDS) assessment, dated 1/7/26, indicated Resident #106 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. The MDS indicated Resident #106 needed partial to moderate assist with activities of daily living (ADLs) and independently ambulated with a rolling walker. Review of the Care Plans indicated Resident #106 received assistance with ADLs, was a fall risk, was at risk for complications related to cirrhosis, and had a history of SUD. Review of the nursing progress notes indicated on 3/1/26 Resident #106 was found using an illegal substance in his/her room and the police and Emergency Medical Services (EMS) were contacted. Resident #106 was transferred to the hospital at this time. During an interview on 3/26/26 at 3:13 P.M., Resident #106 said, They kicked me out. The Resident said the facility told the hospital that he/she was not allowed to return to the facility. The Resident said he/she did not think this was right and that he/she was now homeless. Resident #106 said the facility had been working with him/her on discharge planning and now had nowhere to go and had been in the hospital since March 1st. The Resident said they were not provided with any paperwork regarding their right to appeal the discharge and did not know anything about this. During an interview on 3/23/26 at 11:02 A.M., the Ombudsman said she had concerns regarding the transfer/discharge process and had not received any notices from the facility since December 2025. During an interview on 3/26/26 at 3:44 P.M., Social Worker #1 said she worked for a consultant and had started working at the facility in February 2026. She said she had just found out the week prior that notices of transfer and discharge were not being sent to the Ombudsman. She said she was unfamiliar with Resident #106 and would have to review the discharge and follow up on notices provided. Review of the transfer paperwork included a Resident Notification Regarding Facility Bed Hold Notice and a 30-Day Notice of Intent to Transfer Resident, both dated 3/1/26. The 30-Day Notice of Intent to Transfer Resident contained a section for Reasons for Discharge with multiple options, none of the reasons were checked off. There were no further notices in regard to discharge in the medical record or in the Medical Record office. During an interview on 3/26/26 at 4:28 P.M., Social Worker #1 said the notices for Bed Holds and Transfers were kept in a binder in the Medical Record office. She said the two notices provided to the surveyor were dated 3/1/26 and were sent with the transfer forms when the Resident transferred to the hospital. She said the 30-Day Notice of Intent to Transfer Resident form should have been a Less than 30-Day Notice form as the Resident was not provided with 30 days. She said the facility had determined that Resident #106 was not allowed to return to the facility after the Resident was sent to the hospital and she was not involved in any discharge notices being provided to the Resident when this determination was made. She said the Intent to Discharge form with appeal rights should have been sent directly to the Resident at the hospital. During an interview on 3/26/26 at 4:49 P.M., the Administrator said on 3/1/26 the staff had found Resident #106 with an illegal substance and the Resident was transferred to the hospital. He said the interdisciplinary team met on 3/2/26 and determined the Resident could not return to the facility. The Administrator said he thought the original notice sent with the Resident on 3/1/26 was the correct Intent to Discharge form and no one sent any additional notices after the team discussion to not allow the Resident to return on 3/2/26. During an interview on 3/26/26 at 5:19 P.M., the Admissions Coordinator said the process was for the hospital and facility to communicate through the Admissions Coordinators. She said the Emergency Department had reached out at the beginning of the month regarding the Resident returning to the facility and the Admissions Department had informed the hospital that the facility would not be allowing Resident #106 to return to the facility. She said this was a verbal communication and the Admissions Department did not send any written notice of discharge. During an interview on 3/27/26 at 11:15 A.M., Social Worker #2 said she had worked at the facility on 3/4/26 and was unfamiliar with Resident #106 being sent to the hospital and unable to return. She said she had not sent any intent to discharge notices to the Resident or the hospital. During an interview on 3/27/26 at 1:09 P.M., Social Worker #3 said she had worked at the facility on 3/3/26 and had heard that staff found drug paraphernalia in the room of Resident #106 and the Resident was transferred to the hospital. She said she did not issue any discharge notes to the Resident or the hospital.

Based on observation, interview, and record review, the facility failed to develop and implement the person-centered plan of care for two Residents (#40, #7), out of 21 sampled residents. Specifically, the facility failed to:1. Implement interventions identified on Resident #40's care plan for falls; and2. Develop and implement interventions to address Resident #7's history of suicidal ideations.Findings include:Review of the facility's policy titled Care Plan Policy, revised 5/2025, indicated, but was not limited to, the following:Care Planning - Comprehensive:-Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers.-Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Behavior Care Plans:-Any resident exhibiting behaviors/symptoms must have an individualized behavior care plan in place that addresses specific behaviors.-All behavior care plans are to be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.1. Resident #40 was admitted to the facility in September 2021 with diagnoses including dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and atrial fibrillation with long term use of anticoagulants.Review of Resident #40's Minimum Data Set (MDS) assessment, dated 2/22/26, indicated the Resident was cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Further review of the MDS assessment indicated the Resident sustained one fall with major injury since the previous assessment.Review of Resident #40's medical record indicated that on 2/22/26, the Resident sustained a fall resulting in a nasal fracture. Review of Resident #40's Physician's Orders indicated, but was not limited to, the following:-Chair alarm while out of bed every shift (order date 3/2/26)Review of Resident #40's care plans indicated, but was not limited to, the following:-Problems/Strengths: At risk for falls: weakness-Interventions: 8/16/23: S/P (status post) fall do not leave unsupervised in bathroom, clip alarm at HS (bedtime) only3/3/26: (3/2/26)- Chair alarm in place when OOB (out of bed) (staff to check function and placement when in use)The surveyor made the following observations:-3/25/26 at 2:49 P.M. - Resident #40 was sitting in his/her wheelchair in the unit activity room. The Resident's chair alarm was not in place.-3/26/26 at 9:42 A.M. - Resident #40 was sitting in his/her wheelchair in the unit activity room after breakfast. The Resident's chair alarm was not in place.-3/26/26 at 12:25 P.M. - Resident #40 was in the unit activity room eating lunch in his/her wheelchair. The Resident's chair alarm was not in place.During an interview on 3/26/26 at 12:26 P.M., Unit Manager #2 said Resident #40 had recently had a fall with nasal fracture and should have a chair alarm in place when he/she is out of bed.During an interview on 3/27/26 at 3:42 P.M., the Director of Nursing (DON) said Resident #40's chair alarm was an intervention and should have been in place.2. Resident #7 was admitted to the facility in February 2026 with diagnoses including depression, bipolar disorder, and suicidal ideation.Review of the MDS assessment, dated 2/9/26, indicated Resident #7 was usually understood and usually understands, but no BIMS assessment was completed due to the Resident being rarely/never understood. Further review of the MDS assessment indicated the Resident had diagnoses including dementia, depression, and bipolar disorder and received antidepressant and antipsychotic medication.Review of Resident #7's Hospital Discharge summary, dated [DATE], indicated the Resident had a history of suicidal ideation and inpatient psychiatric hospitalization in September 2025.Review of Resident #7's Physician's Orders indicated, but was not limited to, the following:-Activate HCP (health care proxy) (order date 2/3/26)-Wellbutrin XL (antidepressant medication) 150 mg (milligrams) Give one tab oral every day (order date 2/3/26)-Trazodone (antidepressant medication) 50 mg nightly-Olanzapine (antipsychotic medication) 10 mg nightly (order date 3/9/26)-Lamictal (anti-seizure medication also used to manage bipolar disorder) 150 mg twice daily (order date 2/3/26)Review of Resident #7's consultant Behavioral Health Group progress notes indicated the Resident had diagnoses of dementia with psychotic disturbance and major depressive disorder requiring psychiatric medication but failed to include information regarding Resident's history of suicidal ideation requiring psychiatric hospitalization.Review of Resident #7's Social History assessment, dated 2/4/26, failed to indicate the Resident's history of suicidal ideation requiring psychiatric hospitalization in September 2025.Review of Resident #7's care plan indicated, but was not limited to, the following-Problems/Strengths: Psychotropic medication: Bipolar, depression, dementia with mood disturbance-Interventions: Medicate per MD orders; Observe for onset/worsening of adverse S/Es (side effects); AIMs (Abnormal Involuntary Movement Scale) test Q6M (every six months) and PRN (as needed); Monitor mood and behavior; Notify physician of changes in mood, behavior, and/or for onset/worsening of adverse S/EsReview of Resident #7's care plan failed to include care planning interventions to address the Resident's history of suicidal ideations requiring psychiatric hospitalization in September 2025.During an interview on 3/26/26 at 1:42 P.M., Unit Manager #2 said Resident #7 had not expressed his/her history of suicidal ideation as a concern at the facility. During an interview on 3/27/26 at 3:42 P.M., the DON said Resident #7 should have a care plan for suicidal ideation so that facility staff could monitor the Resident appropriately.

Based on observations, interviews, and records reviewed, for two Residents (#7 and #40), of 21 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed:1. For Resident #7, to document the Resident's 8 P.M. blood sugar levels, amount of sliding scale insulin administered, and the sites of insulin administration;2. For Resident #40, to ensure physician's orders were implemented:a. in response to accepted pharmacy recommendations; andb. for prosthetic eye care.Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Medication Orders, revised November 2014, indicated, but was not limited to, the following:-A current list of orders must be maintained in the clinical record of each resident.-Orders must be written and maintained in chronological order.1. Resident #7 was admitted to the facility in February 2026 with diagnoses including hyperglycemia and diabetes.Review of the Minimum Data Set (MDS) assessment, dated 2/9/26, indicated Resident #7 had a diagnosis of diabetes. Further review of the MDS assessment indicated the Resident received insulin injections and was administered hypoglycemic medications (medications that lower blood sugar levels).Review of Resident #7's Hospital Discharge summary, dated [DATE], indicated the Resident was hospitalized for uncontrolled type 2 diabetes requiring adjustment of his/her diabetic medication regimen and treatment with insulin.Review of Resident #7's care plan indicated, but was not limited to, the following:-Problems/Strengths: Alteration in metabolic function: DM (diabetes mellitus)-Interventions: Medicate as ordered; Monitor blood sugar as ordered per MD's ordered [sic]Review of Resident #7's Physician's Orders indicated, but was not limited to, the following:-Humalog (fast-acting insulin) 100 units / 1 ml (milliliter) solution - Injection per sliding scale half hour before meals and per sliding scale every night at 8 P.M. (order date 2/5/26)Review of Resident #7's progress notes failed to include consistent documentation of the Resident's 8 P.M. blood sugar levels and units of Humalog administered. Review of Resident #7's Physician's progress note, dated 2/11/26, indicated the Resident's A1C (a blood test that provides an average of blood sugar levels over two to three months used to monitor how well the diabetes treatment plan is working) was elevated. Further review indicated the Resident's prescribed Glargine (a long-acting insulin) was increased from 20 units to 22 units and his/her sliding scale insulin was continued.Review of Resident #7's Nurse Practitioner (NP) progress note, dated 2/27/26, indicated the Resident's blood sugar levels were elevated in the 300's despite the use of Glargine 22 units and sliding scale insulin. The NP prescribed an oral hypoglycemic medication, Tradjenta 5 milligrams (mg) daily and blood sugar levels were to be evaluated in one week.Review of Resident #7's NP progress note, dated 3/6/26, indicated the Resident's medications and labs were reviewed. No medication changes were made at that time. The progress note did not indicate if the Resident's blood sugar levels had improved after the addition of an oral hypoglycemic medication.Review of Resident #7's February 2026 and March 2026 Medication Administration Records (MARs) failed to indicate the Resident's 8 P.M. blood sugar levels, number of Humalog units administered at 8 P.M. when/if insulin was required per the Resident's sliding scale order, and site of administration for any 8 P.M. Humalog administrations. During an interview on 3/25/26 at 12:38 P.M., Nurse #8 said the electronic medical record should populate with a box to enter the Resident's blood sugar level, number of units of insulin administered, and site of administration for all sliding scale insulin administrations. Nurse #8 reviewed Resident #7's 8 P.M. Humalog sliding scale order and confirmed that no blood sugar levels, number of units, and sites of administration were documented. Nurse #8 said the order must have been entered incorrectly.During an interview on 3/26/26 at 1:42 P.M., Unit Manager #2 said Resident #7's blood sugar level and number of Humalog units administered should be documented and if it was not there, the order was not entered correctly and needed to be fixed. During an interview on 3/27/26 at 3:42 P.M., the Director of Nursing (DON) said that for Resident #7's 8 P.M. sliding scale insulin, there should have been a place for the nurses to document what the blood sugar level was. The DON confirmed that there had not been documentation of the Resident's 8 P.M. blood sugar levels on the MAR. 2. Resident #40 was admitted to the facility in September 2021 with diagnoses including dementia with behavioral disturbance and depressive episodes.a. Review of Resident #40's consultant pharmacist medication regimen review recommendation forms indicated, but was not limited to, the following:-On 2/4/26, the consultant pharmacist indicated the Resident was prescribed two antidepressant medications (Trazodone and Citalopram) that were due to be reviewed for gradual dose reductions and suggested the prescriber consider a gradual dose reduction of Trazodone to 25 mg at bedtime or Citalopram to 5 mg daily. The physician signed the form on 2/11/26 and indicated he accepted the recommendation to reduce the Resident's Citalopram to 5 mg daily. -On 3/10/26, the consultant pharmacist indicated the Resident's prescriber had accepted the pharmacy recommendation to decrease Citalopram to 5 mg daily on 2/11/26, but the order had not yet been processed.-On 3/10/26, the consultant pharmacist indicated the Resident had an as needed Trazodone order without a stop date and recommended the as needed Trazodone be discontinued or that the facility add a stop date that was less than 14 days from the order's initiation. The physician signed the form on 3/13/26 and indicated that he accepted the recommendation to re-evaluate the medication in 14 days.Review of Resident #40's paper medical record indicated that on 3/13/26, an interim/telephone order had been written to discontinue the Resident's Trazodone order and re-evaluate in 14 days per pharmacy recommendation and decrease the Resident's Citalopram to 5 mg daily. The interim/telephone order form was not signed by a receiving nurse. Review of Resident #40's active Physician's Orders, printed from the electronic medical record, indicated, but was not limited to, the following:-Citalopram 10 mg one tab oral every day (order date 1/16/25)-Trazodone 12.5 mg twice daily as needed for agitation (order date 2/28/26)Review of Resident #40's care plan indicated, but was not limited to, the following:-Problems/Strengths: Alteration in mood: anxiety-Interventions: Medicate as ordered-Problems/Strengths: Psychotropic medication: Trazodone due to dx (diagnosis) depressive episodes, insomnia-Interventions: will be on the lowest dose with improved effectReview of Resident #40's February 2026 and March 2026 MARs indicated:-Resident #40 received Citalopram 10 mg daily-Resident #40 had an order for as needed Trazodone, initiated 2/28/26, with no stop dateDuring an interview on 3/26/26 at 1:42 P.M., Unit Manager #2 reviewed the interim/telephone orders in Resident #40's paper chart with the surveyor. Unit Manager #2 said she had written the order to discontinue the Resident's Trazodone order and re-evaluate in 14 days per pharmacy recommendation and decrease the Resident's Citalopram to 5 mg daily and left it flagged for a nurse assigned to the Resident to implement. Unit Manager #2 did not know why the orders were not implemented. b. Review of Resident #40's medical record indicated the Resident had a prosthetic left eye.Review of Resident #40's paper medical record indicated that an interim/telephone order had been written for the Resident's prosthetic eye care weekly. The interim/telephone order was not dated or signed by a receiving nurse.Review of Resident #40's active physician's orders failed to include orders for the Resident's prosthetic eye care.Review of Resident #40's care plan indicated, but was not limited to, the following:-Problems/Strengths: Vision impairment, r/t (related to) false L (left) eye-Interventions: Remind and assist resident to don (put on) visual appliances daily; keep visual appliances cleanFurther review of Resident #40's care plan failed to include further instructions for care for the Resident's prosthetic eye. Review of Resident #40's February 2026 and March 2026 MARs indicated the Resident was not administered prosthetic eye care. Further review of the March 2026 MAR indicated the Resident received an ophthalmic antibiotic (Ciprofloxacin) and artificial tears 3/1/26-3/4/26. During an interview on 3/26/26 at 1:42 P.M., Unit Manager #2 reviewed the interim/telephone orders in Resident #40's paper chart with the surveyor. Unit Manager #2 said she had written the order for the Resident's prosthetic eye care and left it flagged for a nurse assigned to the Resident to implement. Unit Manager #2 could not recall when she had written the undated interim/telephone order and did not know why the order was not implemented.

Based on interview and record review, the facility failed to address high blood glucose levels over a period of 34 days for one Resident (#66), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revision date March 2025, indicated but was not limited to the following:-The provider and staff will summarize factors contributing to, or conditions affected by, the resident's diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life.-Based on the preceding assessment, including causes and complications, the provider will order individualized interventions, which may include:a. Treatment of underlying condition causing impaired glucose intolerance;b. Physical activity, diet, lifestyle modifications, where feasible and accepted by resident;c. Oral hypoglycemic agents; and/ord. Insulin-The provider will order desired glucose targets and monitoring regimes, as well as parameters for reporting information related to blood sugar management.-The provider will adjust treatments based on these results and other factors such as glycosuria, weight gain or loss, hypoglycemic episodes, etc.-The provider 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.-Staff will notify the practitioner as soon as possible when:b. The resident has blood glucose readings higher than 300 milligrams per deciliter (mg/dl) during all or part of two consecutive days. Resident #66 was admitted to the facility in February 2026 with diagnoses which included Type 2 diabetes mellitus (DM) with hyperglycemia (High blood sugar). Review of the Minimum Data Set (MDS) assessment, dated 3/12/26, indicated Resident #66 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident was cognitively intact. Section N indicated Resident #66 was receiving insulin injections. Review of Resident #66's Physician's Orders indicated but was not limited to the following:-House controlled carbohydrate (HCC), cardiac, double portion breakfast, lunch, and supper, regular, thin, date initiated 3/4/26.-Semglee (insulin glargine) pen 100 IU/1ML solution, inject 30 units subcutaneous every night at 8:00 PM, date initiated 2/20/2026.-Semglee pen 100 IU/1ML solution, inject 15 units subcutaneous twice (BID) daily at 8: AM and 12:00 P.M., date initiated 2/20/26.-Insulin Aspart Flex Pen 100U/1ML solution, inject 15 units at breakfast, lunch, supper. With meals. Date initiated 2/20/26.-Semglee pen 100 IU/1ML solution, inject 15 units subcutaneous every day at 8: AM, date initiated 3/2/2026 Discontinued 3/3/26. Review of Resident #66's March 2026 Medication Administration Record (MAR) indicated medications were administered as ordered. Review of Resident #66's Physician's Orders for obtaining Fasting Blood Sugars (FBS) indicated the following: -Obtain FBS Breakfast, lunch, supper, date initiated 2/20/26 and discontinued on 3/26/26.-Obtained FBS every night at 8:00 P.M., date initiated 2/20/26 and discontinued on 3/26/26. Review of Resident #66's MAR from 2/20/26 through 2/28/26 indicated FBS readings above 300 mg/dL 14 times out of 32 FBS. Review of Resident #66's MAR from 3/1/26 through 3/26/26 indicated FBS readings above 300 mg/dL 24 times out of 97 FBS. Review of Physician and Nurse Practitioner (NP) notes, dated 2/27/26, 2/28/26, 3/17/26 and 3/20/26, did not indicate Resident #66's consistently elevated blood sugars were addressed. During an interview on 3/26/26 at 1:54 P.M., Unit Manager #1 (UM) said she was never made aware of Resident #66's blood sugars being over 300 and they did not show up on the dashboard (electronic medical record alert). UM #1 said if the blood sugars were above 300 it should have flagged and shown on the dashboard which she reviews every morning. Then she would have addressed the high blood sugar levels with the physician or NP. UM #1 said Resident #66 did not have parameters for reporting high blood sugars because he/she was not a sliding scale with the insulin. During an interview on 3/26/26 at 1:59 P.M., Nurse #6 said Resident #66's high blood sugars should have flagged on the dashboard. Nurse #6 reviewed the dashboard and said the high blood sugars never showed as an alert. During an interview on 3/26/26 at 4:24 P.M., the Director of Nurses (DON) said she would have expected the nurses to communicate and document in their nursing notes for any resident with blood sugars over 300. The DON said any blood sugar reading over 300 should have shown up on the dashboard and Resident #66's readings over 300 did not. The DON said the physician was notified today but should have been notified after one week of high blood sugars. During a telephonic interview on 3/26/26 at 4:29 P.M., Physician #1 reviewed her notes and the NP's notes and said they were never notified of Resident #66's high blood sugars and never changed the Resident's insulin dosages. Physician #1 said she would expect the nurses to notify her if a resident's blood sugars were running over 300 for more than a week.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had intact cognition and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 08/13/25, Family Member #1 (Resident #1's Health Care Agent) informed the Unit Manager that Resident #1 had alleged that CNA #1 was rough during the provision of care on 08/10/25, and the Executive Director was not notified until the next day (08/14/25). Findings include:Review of the Facility's Abuse Policy, titled Abuse Prevention Policies and Procedure, dated as revised November 2024, indicated that the Facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after an allegation is made, if the events that cause the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury, to the Executive Director and to officials (including the State Survey Agency) in accordance with state law. Resident #1 was admitted to the Facility in April 2025, diagnoses included stroke. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/14/24, indicated he/she had intact cognition and was dependent on staff to meet his/her care needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/14/25, indicated that during morning meeting on 08/14/25, the Unit Manager reported that she had received a call from Family Member #1 (Resident #1's HCA) on 08/13/25 who said that Resident #1 told her that on 08/10/25, CNA #1 had been rough when she washed his/her (Resident #1's) private area, even after he/she had asked CNA #1 to stop. Review of the Facility's Internal Investigation Report, undated, indicated that on 08/14/25, the Unit Manager reported to the Executive Director during their interdisciplinary daily meeting, that she received a call from Resident #1's family member alleging that CNA #1 had been rough during pericare after Resident #1 told CNA #1 that it was painful. During an interview on 09/16/26 at 12:58 P.M. (which included a review of her written witness statement), the Unit Manager said Resident #1's HCA called her on 08/13/25 to report that Resident #1 told her that on 08/10/25, CNA #1 gave him/her a shower and was very rough when she washed his/her private area. The Unit Manager said she immediately reported the allegation to the Director of Nurses and then reported it to the Executive Director the next day (08/14/25). However, the Unit Manager said she thought the Executive Director was already aware since she told the DON the previous day. During an interview on 09/16/25 at 1:34 P.M., the Director of Nurses (DON) said she was not aware of the allegation of rough care involving Resident #1 until 08/14/25, when the Unit Manager talked about the allegation during their interdisciplinary daily meeting. During an interview on 09/16/25 at 2:17 P.M., the Executive Director said that on 08/14/25, during their interdisciplinary daily meeting, the Unit Manager discussed Resident #1's allegation of rough care and that the Unit Manager assumed that he (Executive Director) was aware since she (Unit Manager) had she reported the allegation to the DON on 08/13/25. The Executive Director said he had not been made aware of the allegation until the meeting (08/14/25). The Executive Director said that either the DON or the Unit Manager should have immediately notified him of the allegation, but they had not. The Executive Director said once he was aware, he then immediately reported the allegation to the State Agency and Police as required and conducted a full investigation.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively impaired, the Facility failed to ensure staff implemented and followed their Policy related to Reporting Resident Abuse Policy, when on 5/22/25, the Hospice Certified Nurse Aide (CNA) reported an allegation of verbal abuse of a resident by a staff member (CNA #1 or CNA #2) to Nurse #1, and Nurse #1 did not immediately report the allegation to their direct Supervisor as required, and facility Administration was not made aware until the next day. Findings include: The Facility Policy titled Reporting Resident Abuse, last reviewed 2/2025, indicated that any staff member who believed that a resident of the Facility has been abused, mistreated or neglected, the individual is required to notify their direct supervisor who will notify the Executive Director or Director of Nursing. Resident #1's medical record indicated he/she was admitted to the Facility during February of 2024. Resident #2's most recent Minimum Data Set (MDS) Assessment, dated 4/07/25, indicated his/her short and long term memory and decision-making skills were impaired. During a telephone interview on 6/18/25 at 12:50 P.M., the Hospice CNA said that on 5/22/25 while caring for Resident #2 [who shared a room with Resident #1] two CNAs (later determined to be CNA #1 and CNA #2) were providing care to Resident #1 (in the next bed) behind a closed privacy curtain. The Hospice CNA said that at one point, one of the two CNAs providing care to Resident #1 told him/her to shut the fuck up. The Hospice CNA said that she called the Hospice Nurse, who was her direct supervisor, to report the allegation and the Hospice Nurse told her to call the nurse who was working on Resident #1's unit. The Hospice CNA said that she called Nurse #1 and told her that she heard one of the CNAs caring for Resident #1 tell him/her to shut the fuck up. During an interview on 6/12/25 at 11:45 A.M., Nurse #1 said that on 5/22/25 the Hospice CNA called her and told her that while two CNAs cared for Resident #1 behind a closed privacy certain, one of the CNAs used the word fuck. Nurse #1 said that because the Hospice CNA told her that she reported the allegation to her supervisor at the Hospice Agency, that she did not report the allegation to her supervisor, the Executive Director or the Director of Nursing. During an interview on 6/12/25 at 11:15 A.M., the Unit Manager said that on 5/23/25 one of the CNAs told her that the Hospice CNA reported that on 5/22/25 there had been a situation with CNA #1 and CNA #2 while caring for Resident #1. The Unit Manager said that she spoke to CNA #2 and CNA #2 told her that CNA #1 swore while providing care to Resident #1. The Unit Manager said that she reported the allegation to the Executive Director. During an interview on 6/12/25 at 12:30 P.M., the Executive Director and Director of Nursing said that on 5/23/25, the Unit Manager reported to them an allegation that on 5/22/25 CNA #1 swore at Resident #1 when caring for him/her. The Executive Director and Director of Nursing said that they reported the allegation to the Department of Public Health and initiated an investigation. On 6/12/25, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction that addressed the concern as evidence by: A. On 5/23/25, the Assistant Director of Nursing educated Nurse #1 on the timeframes for reporting allegations of abuse. B. Resident #1 was assessed for potential for adverse affects related to the use of profanity during care, he/she remains at baseline, will be supported by staff as needed. Social Services and nursing staff check with other residents on CNA #1's assignment, no other concerns were noted. C. On 5/23/25, the Assistant Director of Nursing initiated education of all Facility staff on the reporting requirements for allegations of abuse. Education included Policy review, and staff verbalization of understanding of reporting requirements. D. Since 5/23/25 and on-going, the Executive Director and Director of Nursing review all reported incidents and allegations for timeliness of reporting. E. Concern area was present at the facility's Quality Assurance Performance Improvement Committee (QAPI) meeting, along with corrective action plan and will be followed up on at next QAPI meeting to ensure continued compliance. F. The Executive Director/designee are responsible for overall compliance.

Based on record reviews and interviews, for one Resident (#77), out of a total sample of 23 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #77 with a known history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, physically abusing other residents, being physically abused by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents, the facility failed to ensure staff had appropriate competencies and skill sets to effectively manage his/her behavioral health needs, including developing non-pharmacological interventions. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -The facility provided training on orientation and ongoing to all staff on the Abuse Prevention Policies and Procedures including training on issues relating to abuse risk and prohibition practices such as: -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; see Behavioral Management Policy. -What constitutes abuse, neglect, exploitation, and misappropriation of resident property Review of the facility's policy titled Behavior Management and Response Guidelines, last revised 12/2023, indicated but was not limited to: -Physical aggression is the act of one person physically harming another person for any reason, right or wrong: i.e., hitting, kicking, slapping, pinching, biting, etc. -Any resident who verbally threatens others then refuses verbal redirection from staff is at high risk for assault. All threats toward another resident should be considered real and steps taken to protect the other resident from harm. -Pay particular attention to demented, wandering residents, residents attempting to elope. These residents are more likely to impulsively assault others. -Residents who intrude on other residents' personal areas or who agitate others are more likely to be assaulted than other residents. -A resident may be considered appropriate or one-to-one (1:1) supervision status when he/she presents with an acute problem such as assaultive. -On initiating 1:1, the nurse shall assign a staff member to remain with the resident at all times. This staff member shall not leave the resident unless relieved by another staff member or the nurse removes the resident from 1:1 status. -The assigned staff member shall monitor and supervise the resident at all times, and is responsible for maintaining the resident's safety and welfare. -The assigned staff shall be responsible for documenting the resident's behaviors/activities/unusual events at least each hour. Documentation shall be made using a Behavioral Tracking Sheet, countersigned by the nurse, and placed in the nurses notes section of the resident's chart. -Sexual behavior becomes a problem when a resident acts out his/her behavior toward an unconsenting resident, when it is directed toward staff members or visitors. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU- specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of the medical record indicated documentation of six incidents of physical abuse, sexual abuse, and neglect as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents (female) rooms and touching his/her privates. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent). 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other resident's rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). During an interview on 11/20/24 at 9:50 A.M., the Director of Nursing (DON) reviewed Resident #77's medical record and said all of the allegations of abuse and neglect reviewed should have been identified as such by staff, non-pharmacological interventions put in place, and care plans developed after each incident to address and meet the Resident's behavioral care needs to keep the Resident and any other residents safe. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors is to wander into female residents' rooms, stand at their bedside watching them and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse and did not develop any new interventions to address the behavior. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/19/24 at 11:55 A.M., the consultant psychiatric Nurse Practitioner (NP) #3 said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. NP #3 said he provides staff with guidance on how to manage the Resident's behaviors, but he is not sure about follow through because staff are always different. During an interview on 11/20/24 at 9:50 A.M., the DON reviewed Resident #77's medical record. A Nurse's note, dated 10/22/24 and written by Nurse #14, indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. The DON called Nurse #14 at 10:30 A.M. in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. The DON said staff should have identified the Resident's behavior as sexually inappropriate and developed a care plan with interventions to meet the Resident's behavioral needs. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor or DON and did not put in place any protective measures or interventions to address the behaviors and protect any of the other residents from being assaulted. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to meet his/her behavioral needs and prevent the Resident from abusing others and being abused. During a telephone interview 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24. She said since returning to the facility, she has been tasked with conducting audits of PASARRs (Preadmission Screening and Resident Review) to get the facility's medical records up to date, and has not been notified about any behaviors, has not participated in any discussions, assessments, care plan development or care plan revision for Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The surveyor reviewed with SW #1 the allegations of physical assault of another resident on two occasions (12/14/24 and 2/20/24), having been struck by another resident on two occasions (9/25/24 and 10/10/24), and having sexually harassed/abused other residents on two occasions. She said staff should have addressed these behaviors and developed care plans to meet the Resident's behavioral needs. During an interview on 11/21/24 at 11:15 A.M., the Staff Development Coordinator (SDC) said for a training to be considered effective, she holds herself and the facility to a 75% education threshold. She said there is a total of 163 employees at the facility. Review of mandatory Abuse, Neglect and Exploitation and Behavior training documentation provided by the SDC, including sign-in sheets and course completion documentation from their online training platform, 24 out of 163 (15%) staff completed Behavior training from November 2023 - November 2024. During a follow up interview on 11/21/24 at 2:03 P.M., the SDC said she provided all in-services from November 2023 to current in the facility. She reviewed the completion rate for Behavioral health trainings, and said it was low and she would expect that they would have been in better shape than that with their training compliance. She said the completion percentage was not acceptable and more work appears to be needed to ensure staff are completing trainings. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his Nurse Practitioner (NP #4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he did not think they were doing anything to address the Resident's behaviors to prevent it from happening. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F949

Based on observation, record review, and interviews, the facility failed to provide a safe environment free from physical abuse, sexual abuse, and neglect for one Resident (#77), from a total sample of 23 residents. Specifically, the facility failed to ensure Resident #77, with severe cognitive impairment and a history of aggression, violence, and sexually inappropriate behaviors toward staff and other residents, did not physically and sexually abuse other residents; and that Resident #77 was protected from being physically abused by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -Purpose: To promote prevention, protection, prompt reporting and interventions in response to alleged, suspected, or witnessed abuse/neglect/exploitation of any resident. -There are many types of abuse, including but not limited to: Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse: Includes hitting, slapping, pinching, and kicking. Sexual abuse: Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -All staff receive training on hire, and ongoing, on courses related to abuse risk and prohibition practices. -All staff members, consultants, contractors, volunteers, and other caregivers who provide care and services on behalf of the Facility are responsible for reporting any incident that may constitute or lead to any form of abuse, neglect, or exploitation of our residents. -During the course of any investigation, the safety and protection of all residents is of utmost priority, and the Facility makes provisions to protect residents from harm during investigations. -All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. -The Facility will analyze allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property through the Quality Assessment and Assurance process to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU-specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of comprehensive care plans indicated a care plan for Alteration in Behaviors, dated 12/11/21, indicated but was not limited to the following interventions: -Monitor behavioral episodes every shift. -Monitor for changes in behavior, notify physician of changes noted. -Bring to quiet environment. -Observe to identify potential triggers to escalating behavior. -Provide 1:1 for calming and reassurance. -Observe Resident for intrusive behavior while wandering, intervene as necessary. -Set limits with resident in regard to socially inappropriate behavior. -Withdraw attention from resident during attention seeking, acting out, socially inappropriate behavior; give attention during appropriate behavior. -Tell the Resident that the behavior is unacceptable, that you object to the behavior, not the resident. -Assess to determine if the behavior is a sign of an unmet need (need to toilet, thirst, hunger, discomfort, pain, etc.). -Offer alternative ways for the resident to cope with situations that trigger behavior (i.e., relaxation techniques, breathing techniques, etc.) The goal of the care plan, dated 12/11/21, indicated: -Resident will be effectively redirected from aggressive behavior with each episode daily with a stop guard banner placed across his/her doorway to prevent wanderers (sic). -Resident will demonstrate cooperation with care as evidenced by clean and neat appearance. Further review of comprehensive care plans failed to indicate a care plan had been developed with interventions to prevent Resident #77 from physically abusing other residents, being physically abused by other residents, and prevent sexually inappropriate behaviors toward female residents. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors is to wander into female residents' rooms, stand at their bedside watching them and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse and said they had never reported these behaviors to the Director of Nursing (DON) or Administrator. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/18/24 at 1:43 P.M., the Therapeutic Activity Director (TAD) said Resident #77 now resides on the DSCU. She said when he/she resided on the first floor a few months ago, he/she would stand outside women's rooms and egg them on verbally and with sexually inappropriate gestures. During an interview on 11/19/24 at 11:55 A.M., consultant psychiatric Nurse Practitioner (NP) #3 said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. During an interview on 11/20/24 at 8:55 A.M., Nurse #8 and UM #1 said the only intervention for increased supervision on the unit is purposeful rounding. They defined purposeful rounding as when staff walk around the unit and check in resident rooms. They said there is no schedule for which staff are responsible for purposeful rounding and there is no documentation to confirm it is being done. They said they just assume everyone is doing it. UM #1 said there has not been any increased supervision of Resident #77 in response to his/her ongoing inappropriate sexual behaviors. Review of Resident #77's medical record indicated Resident #77 hit other residents on two occasions (12/14/23 and 2/20/24), was struck by another resident on two occasions (9/25/24 and 10/10/24), and sexually harassed/exhibited sexually inappropriate behaviors toward residents on two occasions (1/3/24 and 2/29/24). Review of the Health Care Facility Reporting System (HCFRS- system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 11/18/24, indicated the facility failed to submit reports of resident-to-resident abuse as required for five of six incidents dated: 12/14/23, 1/3/24, 2/29/24, 9/25/24, and 10/10/24. During an interview on 11/20/24 at 9:50 A.M., the DON said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's violent, sexually inappropriate behavior. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the Resident should probably have been sent out to the hospital via a section 12 (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent), and the physician, HCP and police should also have been notified. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents' (female) rooms and touching his/her privates. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's sexually inappropriate behavior. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the Resident should have been placed on one-to-one (1:1) supervision, sent out to the hospital via a section 12. Review of the medical record indicated an interdisciplinary care plan meeting was held on 1/24/24. However, the current Alteration in Behaviors care plan was reviewed and renewed with no new interventions to address Resident #77's sexually inappropriate behaviors. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident (severely cognitively impaired) in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. Review of the medical record failed to indicate, following the Resident's return to the facility, any protective measures were put in place to protect any residents from being hit by Resident #77. The DON said protective interventions should have been put into place when the Resident returned from the hospital to protect other residents but was not. The DON said the resident that was struck by Resident #77 has severe cognitive impairment, and using the reasonable person concept, the resident would feel frightened and threatened. 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room to check on the resident and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. Further review of the medical record failed to indicate law enforcement was notified of the sexual abuse as required. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77 exposing him/herself to them. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective measures should have been put in place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the police should have been notified and the Resident sent out to the hospital for evaluation. The DON said they probably would not have accepted the Resident back after hospitalization because they are not able to care for his/her behavioral needs. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. Review of the medical record failed to indicate the facility implemented any protective measures to protect Resident #77, who is vulnerable (due to severe cognitive impairment and a history of agitation and aggression), and any other residents from being hit by the unidentified resident. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect Resident #77 from being hit by the unidentified resident but was not. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). Review of the medical record failed to indicate any protective measures were put in place to protect Resident #77, or any other residents from being hit by the unidentified resident. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated and protective interventions put into place to protect Resident #77 and any other residents from being hit by the unidentified resident but was not. During an interview on 11/20/24 at 10:30 A.M., the DON reviewed a Nurse's note, dated 10/22/24 and written by Nurse #14. The note indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. At this time, the DON called Nurse #14 in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. At this time, the DON called UM #2 and told her to place Resident #77 on 1:1 supervision immediately and indefinitely. During a telephone interview on 11/20/24 at 11:45 A.M., Resident Representative (RR) #2 said Resident #77 has resided at the facility for a few years. She said Resident #77 has dementia and it causes him/her to do aggressive and sexual behaviors that are not welcomed by the other residents. RR #2 said not long after the Resident was admitted to the facility, the Administrator called her to discuss transferring the Resident to a locked facility due to concerns for other residents' safety. RR #2 said she did not agree to that because the facility was too far away and the Resident's spouse would not be able to visit him/her very often. She said she is very grateful that the Administrator is allowing the Resident to remain in the facility despite their concerns about the safety of other residents. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor or DON and did not put in place any protective measures or interventions to protect any of the other residents from being assaulted. On 11/20/24 at 3:26 P.M., the surveyor entered the third-floor unit from the stairwell and observed a CNA standing in the hallway entering data into a computer that was mounted on the wall. The CNA was positioned with her back to Resident #77's room which was approximately 40 feet away at the end of the hallway. The surveyor then walked down a perpendicular hallway and observed two nurses and one CNA standing at the nursing station talking. On 11/20/24 at 3:27 P.M., the surveyor observed Resident #77 in his/her room sleeping in a recliner chair with the door to his/her room open and no stop guard banner placed across his/her doorway to prevent wandering residents from entering as indicated on the care plan. No staff were with the Resident to provide 1:1 supervision. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. On 11/20/24 at 3:34 P.M., the surveyor observed Resident #77 standing in the doorway of his/her room looking down the hallway. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. A female resident emerged from a room across the hall and was observed walking down the hallway, turning around and walked to Resident #77's room and entered. A few moments later, the female resident exited Resident #77's room. No staff was providing 1:1. On 11/20/24 at 3:40 P.M., the surveyor observed UM #1 walk in the hallway approximately 50 feet away and notice the surveyor. She then approached CNA #10 and whispered in her ear. At this time, CNA #10 walked down the hallway and approached Resident #77 as he/she stood in the doorway of his/her room. The CNA said that she works on the other hallway and was told to go to Resident #77's room to assist him/her with something, but she didn't know what the Resident needed. The CNA was observed walking up and down the hallway and not providing 1:1 supervision to Resident #77. On 11/20/24 at 3:46 P.M., CNA #9 arrived at Resident #77's room. She said she was there to provide 1:1 supervision until the Helping Hands (staff designated to provide supervision to residents) come to take over. She said Resident #77 has sexually inappropriate behaviors toward females. She said the Resident stands outside female residents' rooms and stares at them and they don't like it. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said they tried to transfer the Resident to another facility for the safety of the Resident and other residents, but the Resident's spouse and daughter became upset and were adamant that he/she not be moved. The Administrator said every time the Resident has a behavioral episode, they contact the family and discuss moving him/her, but the family refuses. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to prevent the Resident from abusing others and being abused. During a telephone interview on 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24 and has not been notified of any incidents or behaviors involving Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The Social Worker said multiple families had come to the administration to complain about the Resident's behaviors. She said she had spoken to RR #2 several times about his/her behaviors and the need to find a safe alternative for the Resident and to prevent an unsavory environment. She said she explained to RR #2 that the Resident's continued behavior may be considered a crime and she wouldn't want her loved one in prison at his/her age. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his NP (#4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he recalls being at the nursing station on the second floor and observed Resident #77 speaking in explicit language. He said staff had concerns about the Resident's behavior specifically because there were multiple female residents on the floor that were ambulatory, and he/she was getting into explicit verbal altercations with them. He said he did not think they were doing anything to prevent it from happening. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he does not recall when or who participated in the conversation he overheard. Multiple attempts to contact NP #4 for an interview were unsuccessful. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F607, F609, F610, F740, F741

Based on observation, record review, and interview, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#77), with a known history of conduct disorder, dementia with behavioral disturbance, and major depression, out of a total sample of 23 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, resulting in wandering intrusively into other residents' rooms; standing at female residents' bedsides and fondling his/her genitals; exposing him/herself to another resident; physically assaulting and being physically assaulted by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Behavior Management and Response Guidelines, last revised 12/2023, indicated but was not limited to: -Physical aggression is the act of one person physically harming another person for any reason, right or wrong: i.e., hitting, kicking, slapping, pinching, biting, etc. -Any resident who verbally threatens others then refuses verbal redirection from staff is at high risk for assault. All threats toward another resident should be considered real and steps taken to protect the other resident from harm. -Pay particular attention to demented, wandering residents, residents attempting to elope. These residents are more likely to impulsively assault others. -Residents who intrude on other residents' personal areas or who agitate others are more likely to be assaulted than other residents. -A resident may be considered appropriate or one-to-one (1:1) supervision status when he/she presents with an acute problem such as assaultive. -On initiating 1:1, the nurse shall assign a staff member to remain with the resident at all times. This staff member shall not leave the resident unless relieved by another staff member or the nurse removes the resident from 1:1 status. -The assigned staff member shall monitor and supervise the resident at all times, and is responsible for maintaining the resident's safety and welfare. -The assigned staff shall be responsible for documenting the resident's behaviors/activities/unusual events at least each hour. Documentation shall be made using a Behavioral Tracking Sheet, countersigned by the nurse, and placed in the nurses notes section of the resident's chart. -Sexual behavior becomes a problem when a resident acts out his/her behavior toward an unconsenting resident, when it is directed toward staff members or visitors. During an interview on 11/13/24 at 9:02 A.M., the Administrator and Director of Nursing (DON) said their Social Worker's last day in the facility was 10/26/24. They said a new Social Worker (SW #1) started on 11/4/24 and works 15 hours a week on Tuesdays, Thursdays, and Saturdays from 5:00 P.M. to 10:00 P.M. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU- specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of the medical record indicated the last social service history quarterly assessment was conducted on 6/18/23. The assessment indicated Resident #77 had delusions/hallucinations, history of psychiatric concerns, was socially inappropriate, verbally abusive, and intrusive. Review of comprehensive care plans indicated a care plan for Alteration in Behaviors, dated 12/11/21, indicated but was not limited to the following interventions: -Monitor behavioral episodes every shift. -Monitor for changes in behavior, notify physician of changes noted. -Bring to quiet environment. -Observe to identify potential triggers to escalating behavior. -Provide 1:1 for calming and reassurance. -Observe Resident for intrusive behavior while wandering, intervene as necessary. -Set limits with resident in regard to socially inappropriate behavior. -Withdraw attention from resident during attention seeking, acting out, socially inappropriate behavior; give attention during appropriate behavior. -Tell the Resident that the behavior is unacceptable, that you object to the behavior, not the resident. -Assess to determine if the behavior is a sign of an unmet need (need to toilet, thirst, hunger, discomfort, pain, etc.). -Offer alternative ways for the resident to cope with situations that trigger behavior (i.e., relaxation techniques, breathing techniques, etc.). The goal of the care plan, dated 12/11/21, indicated: -Resident will be effectively redirected from aggressive behavior with each episode daily with a stop guard banner placed across his/her doorway to prevent wanderers (sic). -Resident will demonstrate cooperation with care as evidenced by clean and neat appearance. Further review of comprehensive care plans failed to indicate a care plan had been developed with interventions to prevent Resident #77 from physically assaulting other residents, being physically assaulted by other residents, and prevent sexually inappropriate behaviors toward female residents. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors are to wander into female residents' rooms, stand at their bedside watching them, and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse, never reported these behaviors to the DON or Administrator and interventions were not put in place to address the behaviors. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/18/24 at 1:43 P.M., the Therapeutic Activity Director (TAD) said Resident #77 now resides on the Dementia Special Care Unit. She said when he/she resided on the first floor a few months ago, he/she would stand outside women's rooms and egg them on verbally and with sexually inappropriate gestures. During an interview on 11/19/24 at 11:55 A.M., the consultant psychiatric Nurse Practitioner (NP #3) said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. During an interview on 11/20/24 at 9:50 A.M., the DON said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. The DON said she was not notified of this incident and no interventions were put in place to address and manage the Resident's violent behavior, and sexually inappropriate behavior to meet his/her behavioral needs. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents (female) rooms and touching his/her privates. The DON said she was not notified of this incident and no interventions were put in place to address and manage the Resident's intrusive wandering and sexually inappropriate behavior to his/her behavioral needs. Review of the medical record indicated an interdisciplinary care plan meeting was held on 1/24/24. However, the current Alteration in Behaviors care plan was reviewed and renewed with no new interventions to address Resident #77's sexually inappropriate behaviors. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident (severely cognitively impaired) in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent). The DON said no interventions were put into place when the resident returned from the hospital to address and manage the Resident's violent behavior and meet his/her behavioral needs. 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other resident's rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room to check on the resident and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. The DON said she was not notified of this incident and no interventions were put into place to address and manage the Resident's sexually inappropriate behavior and meet his/her behavioral needs. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. The facility failed to implement protective measures to protect Resident #77, who is vulnerable (due to severe cognitive impairment and a history of agitation and aggression), from the unidentified resident's violent behavior. The DON said she was not notified of this incident and no interventions were put into place to address and manage the Resident's violent behavior and to meet his/her behavioral needs. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). The DON said she was not notified of this incident and no interventions were put into place to protect Resident #77 from physical abuse by another resident to meet Resident #77's behavioral needs. The DON reviewed a Nurse's note, dated 10/22/24 and written by Nurse #14, that indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. The DON called Nurse #14 at 10:30 A.M. in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. The DON said staff should have identified the Resident's behavior as sexually inappropriate and developed a care plan with interventions to meet the Resident's behavioral needs. At this time, the DON called Unit Manager #2 and told her to place Resident #77 on 1:1 supervision immediately and indefinitely. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor DON and did not put in place any protective measures or interventions to protect any other residents from being assaulted. On 11/20/24 at 3:26 P.M., the surveyor entered the third-floor unit from the stairwell and observed a Certified Nursing Assistant (CNA) standing in the hallway entering data into a computer that was mounted on the wall. The CNA was positioned with her back to Resident #77's room which was approximately 40 feet away at the end of the hallway. The surveyor then walked down a perpendicular hallway and observed two nurses and one CNA standing at the nursing station talking. On 11/20/24 at 3:27 P.M., the surveyor observed Resident #77 in his/her room sleeping in a recliner chair with the door to his/her room open and no stop guard banner placed across his/her doorway to prevent wandering residents from entering as indicated on the care plan. No staff were with the Resident to provide 1:1 supervision. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. On 11/20/24 at 3:34 P.M., the surveyor observed Resident #77 standing in the doorway of his/her room looking down the hallway. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. A female resident emerged from a room across the hall and was observed walking down the hallway, turning around, and walked to Resident #77's room and entered. A few moments later, the female resident exited Resident #77's room. No staff was providing 1:1 supervision. On 11/20/24 at 3:40 P.M., the surveyor observed Unit Manager #1 walk in the hallway approximately 50 feet away and notice the surveyor. She then approached CNA #10 and whispered in her ear. At this time, CNA #10 walked down the hallway and approached Resident #77 as he/she stood in the doorway of his/her room. The CNA said that she works on the other hallway and was told to go to Resident #77's room to assist him/her with something, but she didn't know what the Resident needed. The CNA was observed walking up and down the hallway and not providing 1:1 supervision to Resident #77. On 11/20/24 at 3:46 P.M., CNA #9 arrived at Resident #77's room. She said she was there to provide 1:1 supervision until the Helping Hands (staff designated to provide supervision to residents) come to take over. She said Resident #77 has sexually inappropriate behaviors toward females. She said the Resident stands outside female residents' rooms and stares at them and they don't like it. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said they tried to transfer the Resident to another facility for the safety of the Resident and other residents, but the Resident's spouse and daughter became upset and were adamant that he/she not be moved. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to prevent the Resident from abusing others and being abused. During a telephone interview 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24. She said since returning to the facility, she has been tasked with conducting audits of PASARRs (Preadmission Screening and Resident Review) to get the facility's medical records up to date, and has not been notified about any behaviors, has not participated in any discussions, assessments, care plan development or care plan revision for Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The surveyor reviewed the allegations of physical abuse of another resident on two occasions (12/14/24 and 2/20/24), having been struck by another resident on two occasions (9/25/24 and 10/10/24), and having sexually harassed/abused other residents on two occasions with SW #1. She said staff should have appropriately addressed these behaviors to meet the Resident's behavioral needs. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his Nurse Practitioner (NP #4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he did not think they were doing anything to prevent it from happening. He said he recalls being at the nursing station on the second floor and observed Resident #77 speaking in explicit language. He said staff had concerns about the Resident's behavior specifically because there were multiple female residents on the floor that were ambulatory, and he/she was getting into explicit verbal altercations with them. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he does not recall when or who participated in the conversation he overheard. Multiple attempts to contact NP #4 for an interview were unsuccessful. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F949

Based on interviews and record review, the facility failed to implement their abuse policy for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to ensure nursing staff notified the Director of Nurses (DON) and Administrator about allegations of physical and sexual abuse; keep residents safe by implementing protective measures to prevent further abuse by Resident #77; keep Resident #77 safe by implementing protective measures to prevent further physical abuse by other residents; report and investigate abuse allegations as required; report allegations to the state agency (SA) and law enforcement; and ensure all staff received required abuse training. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -Purpose: To promote prevention, protection, prompt reporting and interventions in response to alleged, suspected or witnessed abuse/neglect/exploitation of any resident. -There are many types of abuse, including but not limited to: Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse: Includes hitting, slapping, pinching, and kicking. Sexual abuse: Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -All staff receive training on hire, and ongoing, on courses related to abuse risk and prohibition practices. -All staff members, consultants, contractors, volunteers, and other caregivers who provide care and services on behalf of the Facility are responsible for reporting any incident that may constitute or lead to any form of abuse, neglect, or exploitation of our residents. -During the course of any investigation, the safety and protection of all residents is of utmost priority, and the Facility makes provisions to protect residents from harm during investigations. -All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. -The Facility will analyze allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property through the Quality Assessment and Assurance process to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated Resident #77 had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of Resident #77's medical record indicated Resident #77 hit other residents on two occasions (12/14/23 and 2/20/24), was hit by another resident on two occasions (9/25/24 and 10/10/24), and sexually harassed/exhibited sexually inappropriate behaviors toward residents on two occasions (1/3/24 and 2/29/24). Review of the Health Care Facility Reporting System (HCFRS- system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 11/18/24, indicated the facility failed to submit reports of resident-to-resident abuse as required for five of six incidents dated: 12/14/23, 1/3/24, 2/29/24, 9/25/24, and 10/10/24. During an interview on 11/20/24 at 9:50 A.M., the Director of Nursing (DON) said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's violent and sexually inappropriate behavior. The DON said she was not made aware of this incident. She said it should have been reported to DPH, investigated, and protective interventions put into place to protect any of the other residents from Resident #77's sexually inappropriate and violent behavior. She said the Resident should probably have been sent out to the hospital via a section 12 (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent), and the physician, HCP and police should also have been notified. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents' (female) rooms and touching his/her privates. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's sexually inappropriate behavior. The DON said she was not made aware of this incident and it should have been reported to DPH and investigated. She said the Resident should have been placed on 1:1 supervision, sent out to the hospital via a section 12, and protective interventions put in place to protect any of the other residents. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. Review of the medical record failed to indicate following the Resident's return to the facility, any protective measures were put in place to protect any residents from being hit by Resident #77. The DON said protective interventions should have been put into place when the resident returned from the hospital to protect any of the other residents from Resident #77's violent behavior. 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. Further review of the medical record failed to indicate law enforcement was notified of the sexual abuse as required. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77 exposing him/herself to them. The DON said she was not made aware of this incident and it should have been reported to DPH, the police notified and the Resident sent out to the hospital for evaluation. She said they should have put protective interventions in place to protect any of the other residents from sexual abuse. The DON said they probably would not have accepted the Resident back after hospitalization because they are not able to care for his/her needs. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. Review of the medical record failed to indicate any protective measures were put in place to protect Resident #77, who is vulnerable (due to severe cognitive impairment and a history of agitation and aggression), and any other residents from being hit by the unidentified resident. The DON said she was not aware of this incident and it should have been reported to DPH, investigated and protective interventions put into place to protect Resident #77 and any of the other residents from physical abuse by the unidentified resident. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). Review of the medical record failed to indicate any protective measures were put in place to protect Resident #77, or any other residents from being hit by the unidentified resident. The DON said she was not made aware of this incident and it should have been reported to DPH, investigated and protective interventions put into place to protect Resident #77 and any of the other residents from physical abuse by the unidentified resident. During an interview on 11/21/24 at 11:15 A.M., the Staff Development Coordinator (SDC) said there is a total of 163 employees at the facility. Review of mandatory Abuse, Neglect and Exploitation and Behavior training documentation provided by the SDC, including sign-in sheets and course completion documentation from their online training platform, indicated 50 out of 163 (30%) staff completed required Abuse, Neglect and Exploitation training and 24 out of 163 (15%) staff completed Behavior training from November 2023 - November 2024. During a Quality Assurance Performance Improvement (QAPI) interview with the Administrator and DON on 11/21/24 at 1:47 P.M., the Administrator said each department manager is responsible for the quality assessment and assurance process in their department. They bring forward quality deficiencies, develop and implement plans of action to correct them, and monitor for effectiveness and make needed revisions to the action plan. The DON said they conduct performance improvement projects annually including care delivery, reporting, and abuse. The Administrator and DON were unable to provide any evidence of communication and coordination with the QAPI program for corrective action and tracking for cases of physical and sexual abuse. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his Nurse Practitioner (NP #4) and the psychiatric NP (#3) to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above with the Physician. He said he was surprised and had not heard of anything like that. He said he did not think they were doing anything to prevent it from happening. He said that some time ago, he overheard nursing staff on the second floor discussing their concerns about Resident #77's inappropriate sexual behaviors and that he/she was a large risk of sexual assault on the unit. He said he does not recall when he overheard the conversation or who participated in the conversation. Multiple attempts to contact NP #4 for an interview were unsuccessful. No additional documentation was provided to the survey team by the time of the exit conference.

Based on observation, interview, and record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs to address the behavior care needs of five Residents (#77, #60, #64, #25, and #105) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 23 residents. Specifically, the facility failed to ensure comprehensive care plans were developed and implemented: 1. For Resident #77, to address the Resident's physically and sexually abusive behavior and address him/her being physically abused by other residents; 2. For Resident #60, to address a history of hypersexual behaviors; 3. For Resident #64, to address using pillows to prevent falls; 4. For Resident #25, to address transferring in and out of his/her scoot chair (mobility chair that reduces falls and improves comfort for users who propel themselves with their feet) for meals; and 5. For Resident #105, to address wandering. Findings include: Review of the facility's Care Plan Policy, last revised May 2017, indicated but was not limited to: -Each comprehensive care plan is designed to: -Incorporate identified problem areas; -Incorporate risk factors associated with identified problems; -Reflect treatment goals, timetables and that objectives are measurable; -Aid in preventing or reducing declines in the resident's functional status and/or functional levels; -Reflect current recognized standards of practice for problem areas and conditions. -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. -The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted to the facility from a hospital stay; and -At least quarterly 1. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of comprehensive care plans indicated a care plan for Alteration in Behaviors, dated 12/11/21, indicated but was not limited to the following interventions: -Monitor behavioral episodes every shift. -Monitor for changes in behavior, notify physician of changes noted. -Bring to quiet environment. -Observe to identify potential triggers to escalating behavior. -Provide 1:1 for calming and reassurance. -Observe Resident for intrusive behavior while wandering, intervene as necessary. -Set limits with resident in regard to socially inappropriate behavior. -Withdraw attention from resident during attention seeking, acting out, socially inappropriate behavior; give attention during appropriate behavior. -Tell the Resident that the behavior is unacceptable, that you object to the behavior, not the resident. -Assess to determine if the behavior is a sign of an unmet need (need to toilet, thirst, hunger, discomfort, pain, etc.). -Offer alternative ways for the resident to cope with situations that trigger behavior (i.e., relaxation techniques, breathing techniques, etc.). Further review of comprehensive care plans failed to indicate a care plan had been developed with interventions to prevent Resident #77 from hitting other residents, being hit by other residents and prevent sexually inappropriate behaviors toward female residents. Review of Resident #77's medical record indicated Resident #77 hit other residents on two occasions (12/14/23 and 2/20/24), was hit by another resident on two occasions (9/25/24 and 10/10/24), and sexually harassed/exhibited sexually inappropriate behaviors toward residents on two occasions (1/3/24 and 2/29/24). During an interview on 11/20/24 at 9:50 A.M., the Director of Nursing (DON) said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: -Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. The DON said she was not notified of this incident. She said a care plan should have been developed to address the Resident's hitting behavior and sexually inappropriate behavior but was not. -Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents (female) rooms and touching his/her privates. The DON said a care plan should have been developed to address the Resident's hitting and sexually inappropriate behaviors to prevent it from recurring but was not. She said using the reasonable person concept, the resident would feel frightened and threatened. Review of the medical record indicated an interdisciplinary care plan meeting was held on 1/24/24. However, the current Alteration in Behaviors care plan was reviewed and renewed with no new interventions to address Resident #77's sexually inappropriate behaviors. -Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident (severely cognitively impaired) in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent). The DON said, following the Resident's return from the hospital, a care plan should have been developed to address the Resident's hitting behavior to prevent it from recurring but was not. She said the resident that was struck by Resident #77 has severe cognitive impairment, and using the reasonable person concept, the resident would feel frightened and threatened. -Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room to check on the resident and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. The DON said a care plan should have been developed to address the Resident's sexually inappropriate behaviors to prevent it from recurring but was not. She said using the reasonable person concept, the resident would feel frightened and threatened. -Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. The DON said a care plan should have been developed with interventions to protect Resident #77 from being hit by other residents but was not. -Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). The DON said a care plan should have been developed with interventions to protect Resident #77 from being hit by other residents but was not. 2. Resident #60 was admitted to the facility in July 2022 with diagnoses including dementia with behavioral disturbance. Review of the MDS assessment, dated 11/11/24, indicated Resident #60 had moderate cognitive impairment as evidenced by a BIMS score of 8 out of 15, exhibited behavioral symptoms and wandering. Review of Nurse Practitioner (NP) #4's note, dated 2/23/24, indicated Resident #60 has a history of inappropriate sexual behaviors of trying to kiss other residents and grabbing their breasts. Further review of the medical record indicated Resident #60 was sent to the hospital via section 12 on 12/23/23 and 12/26/23 due to hypersexual behaviors (touching other residents). Review of the consultant psychiatric NP #4's note, dated 6/4/24, indicated Resident #60 exhibited some hypersexual behaviors (verbal). Review of comprehensive care plans failed to indicate an active care plan with individualized interventions for the Resident's history of hypersexual behaviors was developed. During a telephone interview on 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said when there is a behavioral incident, it prompts a risk meeting, a care plan should be developed and put into place to assist the Resident and keep other residents safe. 48695 3. Resident #64 was admitted to the facility in May 2018 with diagnoses including contracture of muscle and dementia. Review of the MDS assessment, dated 11/11/24, indicated Resident #64 had a severe cognitive deficit as evidenced by staff interview and was dependent for bed mobility and transfers in/out of bed. Review of Resident #64's Fall Incident Reports, dated 9/2/24, 9/30/24, and 10/14/24, indicated he/she had fallen out of bed on three occasions. The surveyor observed Resident #64 in bed with pillows tucked under a fitted sheet on both sides of his/her torso down to his/her mid-thigh and a floor mat on the right side of his/her bed as follows: -11/13/24 at 11:31 A.M. -11/14/24 at 12:37 P.M. -11/18/24 at 7:30 A.M. Review of Resident #64's care plans did not indicate the floor mat or the pillows for positioning were on the care plan. During an interview on 11/18/24 at 7:30 A.M., Certified Nursing Assistant (CNA) #8 said Resident #64 is unable to transfer out of bed on his/her own, so the pillows are not a restraint. CNA #8 said Resident #64 utilizes the pillows to prevent him/her from sliding out of bed. CNA #8 said the floor mat was utilized to help cushion the ground and reduce injury in the event Resident #64 had a fall. During an interview with observation on 11/18/24 at 7:33 A.M., Nurse #10 and the surveyor observed Resident #64 in bed positioned on his/her back. Resident #64 had two pillows tucked under his/her fitted sheet on both sides of his/her bed and a gray floor mat on the right side of his/her bed. Nurse #10 said the use of the pillows for Resident #64 should be in his/her care plan as they are used as a safety reminder, but it is not. Nurse #10 said the floor mat should be on the care plan but was not. During an interview on 11/20/24 at 11:22 A.M., the DON said the expectation was for care plans to be individualized to each resident and their needs. The DON said Resident #64's care plan should have been updated to include the floor mat and pillows as they are used as a safety reminder, but it was not. 4. Resident #25 was admitted to the facility in March 2021 with diagnoses including unspecified falls and dementia. Review of the MDS assessment for Resident #25, dated 11/4/24, indicated severely cognitively impaired as evidenced by staff interview and was dependent for transfers. The surveyor observed Resident #25 eating in his/her scoot chair at a table in the floor dining room with the tables at his/her chin level as follows: - 11/14/24 at 8:32 A.M. - 11/14/24 at 11:46 A.M. - 11/15/24 at 8:30 A.M. Review of Resident #25's Positioning Care Plan indicated but was not limited to: -Problem: Physical Mobility Impaired Related to increased fall risk, decreased sitting balance and tolerance (9/10/24) -Approach: scoot chair Review of Occupational Therapy Notes, dated 9/16/24, indicated but was not limited to: - Table height at chest level not optimal for meals. Pt (Patient) should transfer to standard arm chair (sic) for meals. During an interview on 11/19/24 at 10:53 A.M., the Certified Occupational Therapist Assistant (COTA) said she had written the recommendation to transfer Resident #25 to an armchair for meals. The COTA said she did not know who updates the nursing care plans but she does not update them. During an interview on 11/19/24 at 10:57 A.M., Nurse #4 and Nurse #5 reviewed Resident #25's care plans. Nurse #4 said Resident #25's care plans were not updated to indicate he/she should be transferred to a standard armchair for meals. Nurse #5 said care plans should be implemented when an intervention is identified. During an interview on 11/21/24 at 9:05 A.M., the Occupational Therapist (OT) said she was the OT treating Resident #25 along with the COTA. The OT said she did not have access to Resident #25's nursing care plan and did not know how to update them. During an interview on 11/21/24 at 11:41 A.M., MDS Nurse #2 said the MDS Department would only update care plans for new diagnoses or if something was triggered while doing the MDS. MDS Nurse #2 said she would tweak a care plan if she noticed something was missing. MDS Nurse #2 said usually the nurses on the units would update resident specific care plans to add interventions for equipment. MDS Nurse #2 reviewed Resident #25's care plans and said Resident #25's care plans were not updated to include an intervention to transfer to a standard armchair for meals but should have been. During an interview on 11/21/24 at 12:28 P.M., Nurse #7 said usually the Unit Managers, or the DON would update care plans. Nurse #7 said nurses can update care plans but don't always have time to. During an interview on 11/20/24 at 11:22 A.M., the DON said the expectation was for care plans to be individualized to each resident and their needs. The DON said anyone can update the care plan. The DON said Resident #25's care plan should have been updated to indicate he/she should be transferred to a standard armchair for meals but it was not. 48362 5. Resident #105 was admitted to the facility in August 2024 with diagnoses including dementia, depression and anxiety. Review of Resident #105's MDS assessment, dated 8/27/24, indicated the Resident had a severe cognitive impairment as evidenced by a BIMS score of 1 out of 15. Further review of the MDS assessment indicated Resident #105 had wandering behaviors and was able to ambulate without an assistive device at a supervision level. On 11/13/24 at 8:17 A.M., the surveyor observed the following: - Resident #105 wandering on the unit without an assistive device. - Resident #105 having periods of stopping by staff members while wandering on the unit. - Resident #105 tearful at times while walking up and down the hallways of the unit. - Resident #105 was redirected by staff and continued wandering up and down the unit's hallways. On 11/18/24 at 9:44 A.M., the surveyor observed the following: - Resident #105 wandering on the unit without an assistive device. - Resident #105 having periods of stopping by staff members while wandering on the unit. - Resident #105 was redirected by staff and continued wandering up and down the unit's hallways. On 11/18/24 at 12:39 P.M., the surveyor observed the following: - Resident #105 wandering on the unit without an assistive device. - Resident #105 having periods of stopping by staff members while wandering on the unit. - Resident #105 was redirected by staff and continued wandering up and down the unit's hallways. Review of Resident #105's nursing progress notes indicated he/she: - frequently wanders on the unit; - had periods of increased anxiety, restlessness and weepiness while wandering on the unit; and - had periods of confusion while wandering on the unit, requiring redirection by staff. Review of Resident #105's medical record failed to indicate an individualized comprehensive care plan related to wandering. During an interview on 11/19/24 at 11:49 A.M., Unit Manager (UM) #1 said comprehensive care plans are developed on admission and updated at least on a quarterly basis. UM #1 said comprehensive care plans can be updated more frequently if new areas of concern or changes in status are identified and should identify areas specific to the resident. UM #1 said Resident #105 constantly wanders up and down the hallways of the unit and at times needs to be redirected. UM #1 said Resident #105's wandering behaviors should be identified on a comprehensive care plan. UM #1 reviewed Resident #105's comprehensive care plans and said there was not currently one related to wandering. During an interview on 11/19/24 at 12:12 P.M., the DON said comprehensive care plans should be individualized to a resident's status and areas of concern and can be updated by any nursing staff member; care plans are typically updated at least quarterly. The DON said if a new concern arises before a quarterly review, it should be immediately identified on the comprehensive care plan. The DON said comprehensive care plan should always be implemented for behaviors such as wandering.

Based on record review and interview, the facility failed to ensure staff thoroughly investigated five allegations of abuse and neglect, put measures in place to prevent further abuse and neglect, and report the results of the investigations for one Resident (#77), out of a total sample of 23 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -The Facility has procedures to investigate different types of incidents and to identify the staff member responsible for the initial reporting, investigation of the alleged violations and reporting of results to the proper authorities. -During the course of any investigation, the safety and protection of all residents is of utmost priority, and the Facility makes provisions to protect residents from harm during investigations. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others), and wandering. The MDS indicated Resident #77 had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of the medical record indicated documentation of five incidents of physical abuse, sexual harassment/sexually inappropriate behavior, and neglect as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents' (female) rooms and touching his/her privates. 3. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. 4. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. 5. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). During an interview on 11/18/24 at 10:32 A.M., Unit Manager #1 (UM #1) and Nurse #13 said Resident #77 can be aggressive and sexually inappropriate. Nurse #13 said that these behaviors are a part of having dementia. Unit Manager #1 said one of the Resident's baseline behaviors is to wander into female residents' rooms, stand at their bedside and fondle his/her genitals. The UM did not identify this behavior as sexual abuse and therefore did not report it to the supervisor or Director of Nursing (DON) to prompt an investigation, and no interventions were put into place to keep any other residents safe. During an interview on 11/20/24 at 9:50 A.M., the DON said she reviewed the five allegations of abuse and neglect documented in the medical record. She said none of the allegations were investigated and no protective measures were put in place during the investigation to prevent further abuse. During a telephone interview in the presence of the DON on 11/20/24 at 10:30 A.M., Nurse #14 said she is an agency nurse and hasn't worked at the facility since 10/22/24. She said when she worked on 10/22/24, Resident #77 approached her, removed his/her genitals from their pants and shook it at her. She said she told nursing staff on the unit and was told that the behavior was baseline for the Resident, and he/she does it all the time. Nurse #14 said she was told that verbal sexually inappropriate behavior and trying to get into bed with female residents was also baseline behavior for this Resident, and no interventions were put into place to protect any residents from Resident #77's sexually inappropriate behavior. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not put any protective measures in place or interventions to protect any of the other residents from being assaulted. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said he has spoken to the Resident's family after each occurrence. He said all allegations of abuse and neglect should be investigated. He could not explain why the above noted allegations were not investigated as required. No additional documentation was provided to the survey team by the time of the exit conference.

Based on interviews and record review, the facility failed to report allegations of abuse and neglect for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to report five of five allegations of physical abuse, sexual abuse, and neglect to the state agency (SA) and two of five allegations to law enforcement as required. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually harassed and exposed to another person's genitals. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -There are many types of abuse, including but not limited to: Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse: Includes hitting, slapping, pinching, and kicking. Sexual abuse: Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -All staff members, consultants, contractors, volunteers, and other caregivers who provide care and services on behalf of the Facility are responsible for reporting any incident that may constitute or lead to any form of abuse, neglect, or exploitation of our residents. -Immediate action will be taken against anyone who abuses a resident, or anyone fails to report witnessed or suspected abuse in accordance with specified time frames once it becomes known that he/she had prior knowledge of such information. -All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. -The Facility conducts annual notification of covered individuals of their obligation to comply with requirements to report to the State Agency and one or more law enforcement entity, any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the Facility. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others), and wandering. The MDS indicated Resident #77 had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. During an interview on 11/18/24 at 10:32 A.M., Unit Manager #1 and Nurse #13 said Resident #77 can be aggressive and sexually inappropriate. Nurse #13 said that these behaviors are a part of having dementia. Unit Manager #1 said one of the Resident's ongoing behaviors is to wander into female residents' rooms, stand at their bedside and fondle his/her genitals. She said she has not reported any episodes of this behavior to the supervisor or Director of Nursing (DON). Review of the medical record indicated documentation of five incidents of physical abuse, sexual abuse, and neglect as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents' (female) rooms and touching his/her privates. 3.Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. 4. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. 5. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). Review of the Health Care Facility Reporting System (HCFRS- system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 11/18/24, indicated the facility failed to submit reports of resident-to-resident abuse as required for five of five incidents dated: 12/14/23, 1/3/24, 2/29/24, 9/25/24, and 10/10/24. During an interview on 11/20/24 at 9:50 A.M., the DON reviewed Resident #77's medical record and said all of the allegations of abuse and neglect reviewed should have been identified as such by staff and reported to the SA. She said the incidents that occurred on 12/14/23 and 2/29/24 should have also been reported to law enforcement. The DON said using the reasonable person concept, the residents would feel frightened and threatened. During a telephone interview in the presence of the DON on 11/20/24 at 10:30 A.M., Nurse #14 said she is an agency nurse and hasn't worked at the facility since 10/22/24. She said when she worked on 10/22/24, Resident #77 approached her, removed his/her genitals from their pants and shook it at her. She said she reported it to staff on the unit and was told that the behavior was baseline for the Resident and he/she does it all the time. Nurse #14 said she was told that verbal sexually inappropriate behavior and trying to get into bed with female residents was also baseline behavior for this Resident. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor or DON and did not put in place any protective measures or interventions to protect any of the other residents from being assaulted. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said he has spoken to the Resident's family after each occurrence. He said all allegations of abuse and neglect should be reported to the SA and/or law enforcement. He could not explain why the above noted allegations were not reported as required. No additional documentation was provided to the survey team by the time of the exit conference.

Based on observation, document review, and interview, the facility failed to ensure one Resident (#72), who was identified as being a high risk for skin breakdown, out of a total sample of 23 residents, received the care and services per professional standards of practice to help prevent the development of a facility acquired Stage III (full thickness tissue loss) right heel pressure ulcer and promote optimal wound healing. Specifically, the facility failed to implement recommendations made by the Wound Care Specialist timely and develop and implement a care plan that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries. Findings include: Review of the facility's policy titled Pressure Injury Policy, revised July 2024, indicated but was not limited to the following: -On admission or re-admission, the licensed nurse will assess the resident's skin to identify and document existing skin areas. -The licensed nurse will assess each resident's risk for skin breakdown by completing a Norton Plus Pressure Ulcer Scale Form on admission, re-admission, and monthly. If the assessment identified the resident is at risk for skin breakdown, the nurse will implement a care plan to include preventative measures. Stage 3 Pressure Injury: Full thickness skin loss -Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscure the extent of tissue loss this is an unstageable pressure injury. Review of the facility's policy titled Preventive Skin Care Protocol, revised August 2024, indicated but was not limited to the following: Purpose: -To identify adults at risk and to define early intervention for prevention of pressure injury. Goals: -To identify at-risk residents who need prevention and to identify specific factors placing them at risk. -To identify resident specific protocols to reduce risk. -Weekly, residents with alterations in skin integrity will be reviewed by the management team and plan of care including current treatment, effectiveness of treatment, need to revise treatment, nutritional needs and other aspects of care potentially affecting wound healing. -Evaluate new admissions to determine if they are at high risk for the development of pressure injury as well as residents at high risk for development of pressure injury per the Norton Plus Assessment. Determine if preventative protocol is required. Ongoing Assessments: -All residents are to be assessed once each week by the licensed nurse during skin rounds. The results of this hands-on physical skin check are to be recorded on the resident's record. All noted Stage I-Stage IV areas are to be recorded on the skin care treatment sheet per the pressure injury policy. -Resident Severely at Risk: Norton Scale Score = 15 or less Resident #72 was admitted to the facility in July 2024 and had diagnoses including muscle weakness, need for assistance with personal care, unsteadiness on feet, unspecified abnormalities of gait and mobility, acute embolism and thrombosis of deep veins of right upper extremity, type 2 diabetes mellitus with diabetic neuropathy, obesity, and presence of other cardiac implants and grafts. Review of the admission Physician's Progress Note, dated 7/29/24, indicated Resident #72 had a history of peripheral artery disease, type 2 diabetes mellitus, and non-healing wounds and the Resident's skin was warm and dry. Review of the Admission/Re-Admission Nursing Assessment, dated 7/26/24, indicated but was not limited to the following: Skin Condition Comments: -Healed areas bilateral lower extremities, skin dry. No open areas noted. General Skin Condition: -Dry, warm Review of the admission Weekly Skin Assessment, dated 7/26/24, indicated Resident #72 had no pre-existing skin problems or any new skin problems. Review of the admission Norton Plus Pressure Ulcer Scale (Norton Scale), dated 7/26/24, indicated Resident #72 had an assessment score of 8 which indicated he/she was a high risk for the development of pressure related ulcers/injuries. Review of the Resident's medical record failed to indicate a care plan had been developed and implemented upon admission to include preventative measures once the Resident was determined to be a high risk for the development of pressure related ulcers/injuries per the Norton Scale assessment. Review of the Minimum Data Set (MDS) assessment, dated 8/1/24, indicated Resident #72 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, was not a risk for developing pressure ulcers, had no unhealed pressure ulcers, and was frequently incontinent of urine and stool. The MDS indicated the Resident was dependent on staff for toileting, showering, bathing, personal hygiene, sitting to lying, lying to sitting, rolling left to right, chair to bed transfers, and putting on and taking off footwear. Resident #72 also required substantial to maximum assist with toilet transfers and upper and lower body dressing. Review of the Norton Scale, dated 8/2/24, indicated Resident #72 had an assessment score of 6 which indicated the Resident was a higher risk for pressure ulcer development since the previous assessment on 7/26/24 (a lower score indicates a higher risk). A care plan was not developed or implemented to include preventative measures. Review of the Norton Plus Pressure Ulcer Scale, dated 9/1/24, indicated Resident #72 had an assessment score of 9 which indicated the Resident was a high risk for pressure ulcer development. A care plan was not developed or implemented to include preventative measures. Review of Weekly Skin Assessments, dated 8/5/24, 8/13/24, 8/20/24, 8/27/24, and 9/4/24, did not identify any alteration in skin integrity to the Resident's right heel. Review of the Weekly Skin Assessment, dated 9/11/24, completed by Unit Manager (UM) #2, indicated a new skin problem as follows: -half dollar size open area right heel, wound bed dry, edges macerated, no odor, no pain, surrounding skin fragile Review of the medical record failed to indicate UM #2, after identifying an open area on the Resident's right heel, developed a plan of care to include the problem, goals and desired outcomes, specific interventions to achieve those goals, a plan to evaluate and monitor the effectiveness of interventions, or any other aspects of care potentially affecting wound healing. During a telephone interview on 11/20/24 at 8:43 A.M., with the Director of Nursing (DON) and UM #2, UM #2 said that when she identified the right heel pressure area on 9/11/24 during the skin check, she forgot to develop a care plan with interventions for preventive measures. Review of the Wound Care Specialist's initial visit note, dated 9/12/24, indicated but was not limited to the following: Patient was seen for a pressure ulcer right heel. Will update treatment plan. Educated patient and nursing on the importance of offloading and treatment plan. Will recommend offloading boots. Please follow facility pressure ulcer prevention protocol. -Duration: First evaluated on 9/12/24 -Primary Etiology: Pressure -Stage/Severity: Stage III -Wound Status: New -Size: 4 centimeters (cm) x 4 cm x 0.3 cm Assessment/Plan: Avoid friction/sheer/traumatic forces. Facility pressure ulcer prevention protocol. Offload heels per facility protocol. Offload pressure/reposition patient every two hours. Review of the Wound Care Specialist's visit note, dated 10/3/24, indicated but was not limited to the following: Patient was seen for a pressure ulcer right heel. Wound has remained stable in size. Will update treatment plan due to odor and erythema. Will recommend wound culture and sensitivity. Educated patient and nursing on the importance of offloading and treatment plan. Will recommend offloading boots and offloading shoes based on therapy's recommendations. Please follow facility pressure ulcer prevention protocol. -Primary Etiology: pressure -Stage/Severity: Stage 3 -Wound Status: Worsening -Odor Post Cleansing: Malodorous -Wound Base: 100% slough (yellow/white material in wound bed) -Peri wound: Erythema (redness) -Size: 3.5 cm x 3.5 cm x 0.3 cm Assessment/Plan: Avoid friction/sheer/traumatic forces. Facility pressure ulcer prevention protocol. Offload heels per facility protocol. Offload pressure/reposition patient every two hours. Wound culture and sensitivity on heel. Review of a Nurse Progress Note, dated 10/3/24, indicated but was not limited to the following: -Wound MD in to see resident. Wound deteriorated since last week, large area of necrotic dark tissue, foul odor, no pain, minimal drainage. Recommendation for wound culture and start antibiotic. Orders in place to offload right heel with free boot at all times. Review of current Physician's Orders indicated the following: -May have off-loading boot to right heel as recommended by wound care specialist NP every shift, 10/4/24 (22 days after initial recommendation) -Heel free boot to be worn at all times while in bed every shift, 10/3/24 -Ammonium Lactate 12% lotion topical every day on 2-10 shift, 9/22/24 -Offload right heel at all times every shift, 9/20/24 -Skin check day shift, weekly on Thursday, 9/20/24 Review of a Nurse Progress Note, dated 10/6/24, indicated but was not limited to the following: -Labs reported to Nurse Practitioner (NP) for wound culture, +MRSA. Antibiotic changed. Review of the medical record failed to indicate preventative protocol recommendations made by the Wound Care Specialist were initiated and implemented timely to promote wound healing and help prevent any worsening of the existing right heel pressure ulcer and new ulcers from developing. Review of Resident #72's Comprehensive Care Plans failed to indicate a care plan had been developed and implemented for the Resident's risk of or actual development of a right heel Stage III pressure ulcer until 10/4/24, three months after being identified as a high risk for pressure ulcer development upon admission and 23 days after the area was first identified on 9/11/24. During an observation with interview on 11/18/24 at 10:47 A.M., the surveyor observed Resident #72's right heel pressure ulcer with Nurse #3 who said the Resident had a pressure ulcer there but wasn't sure what stage it was. She said she thought the Resident came in with it. She said the Resident needed some assistance with turning and repositioning. Resident #72 said he/she got it from rubbing against his/her shoe. The wound was approximately 4 cm x 4 cm x unstageable (depth is obscured by eschar in the wound bed). The surrounding skin was thick, dry, and scaly. There was no drainage observed. During an interview on 11/19/24 at 11:10 A.M., the surveyor reviewed Resident #72's medical record with Nurse #3 who said the Resident was admitted in July 2024 and there was no care plan in place upon admission to help prevent pressure ulcers from forming. She said the 7/26/24 Norton Scale indicated the Resident was a high risk for developing pressure ulcers and a care plan should have been put into place but wasn't. She said the first documentation about the wound she could find was from a 9/11/24 skin assessment and the wound consultant was there the next day. She said the wound had deteriorated per a 10/3/24 nurse's note with necrotic (dead) tissue and antibiotic therapy was ordered. Nurse #3 said if a resident is identified as being a high risk for developing pressure ulcers upon admission, orders are put into place for prevention and a care plan put into place to prevent any pressure ulcers or pressure injuries from occurring. During an interview on 11/19/24 at 1:01 P.M., the Director of Nursing (DON) said she could not locate a care plan, current or resolved, for the Resident's skin until October but would keep looking. She said at this time, the Resident did not have a care plan in place upon admission to prevent any skin alteration. During an interview on 11/19/24 at 1:49 P.M., the DON said there was no care plan in place upon admission for skin prevention, I can't find one. During an interview on 11/19/24 at 3:25 P.M., the Wound Care Specialist said she saw Resident #72 for the first time on 9/12/24 and staged the right heel pressure ulcer (PU) as a 3. She said the wound ended up getting infected with MRSA and the Resident was started on antibiotics. She said the wound has since gotten smaller in size, but the slough dried out and is stable eschar (dead tissue) now with the current wound treatment ordered. She said she wasn't sure if the PU was new for the Resident, but it was the first time she was notified to see the resident. She said she started at the facility in August 2024 and the first time she met the Resident was on 9/12/24. She said she's pretty sure she was the only wound physician at the facility since the end of July. She said her recommendations had included an offloading boot and offloading in general. She said she didn't know of any pre-existing conditions at this time. During an interview on 11/20/24 at 8:22 A.M., the DON said the Resident was admitted in July 2024 and did not have any skin issues when he/she came in. She said the Norton Scale is used to assess for a resident's risk of developing pressure ulcers and the Resident had a [NAME] done on the day of admission and was a high risk. She said if the Resident was considered a high risk for developing pressure ulcers, then he/she should have had a care plan with preventative measures implemented to offload the pressure to prevent any unavoidable pressure ulcers. She said not having these along with the Resident's co-morbidities could have led to the development of his/her pressure area. The DON said the care plan was not developed and implemented until 10/4/24 but was first identified on a 9/11/24 skin assessment. She said when the nurse first identified it, she should have initiated a care plan and put preventative measures in place, but it wasn't done until 10/4/24. She said the Resident has only seen the Wound Care Specialist. She said the facility used to use another wound consultant, but they never saw this Resident for any skin issues. The DON said she was made aware on 9/11/24 that the Resident had a wound and asked for him/her to be seen by a wound specialist and followed for wound care and she had notified the physician but didn't initiate a care plan for it. She said the Resident had a new pressure ulcer wound that was acquired in the facility.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls and required extensive assistance of two staff members for bed mobility and transfers, the Facility failed to ensure Resident #1's safety was maintained to prevent an incident resulting in injury, when on 10/02/21 Certified Nurse Aide (CNA) #1 provided incontinent care to Resident #1 by herself and did not seek assistance from another staff member. While CNA #1 was turning Resident #1 onto his/her right side, Resident #1 rolled out of of bed onto the floor. Resident #1 was transferred to Hospital Emergency Department for further evaluation and was diagnosed with a fracture to his/her right leg and a head contusion. Findings include: The Facility's Policy titled, Quality Assurance and Performance Improvement Resident's Falls, dated 08/2019, indicated its purpose to promote resident safety and an environment free from falls to the extent possible in consideration of the resident's right to maintain autonomy and to make individual choices. Resident #1 was admitted to the Facility in July 2020, diagnoses included Dementia, muscular weakness and age related physical disability. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assist of two persons with activities of daily living including bed mobility and incontinence care. Review of Resident #1's Plan of Care Interventions related to Decline in Functional Mobility, dated 08/23/21, indicated Resident #1 required extensive assistance of two staff members with bed mobility, transfers, dressing, toileting tasks, bathing and wheelchair mobility due to muscle weakness. Review of the Facility's Investigation Report, dated 10/04/21, indicated that Resident #1 was rolled out of bed during care and he/she fell on to the floor. The Report indicated that Resident #1 was transferred to the hospital where he/she was diagnosed with fracture to his/her right leg. Review of Resident #1's Interdisciplinary Progress Notes, dated 10/02/21, indicated that at 05:15 A.M., Nurse #1 was informed that Resident #1 had fallen. The Note indicated that CNA #1 was assisting Resident #1 in bed when he/she rolled off the bed on to his/her right side. The Note indicated that Nurse #1 observed Resident #1's with a right shin protrusion, right foot internally rotated, and right great toe misalignment with bleeding on the edge of the toe. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for further evaluation. During an interview on 11/05/21 at 12:28 P.M., Nurse #1 said she was providing care to another resident when she heard Resident #1's bed alarm sound and CNA #1 yelling for help. Nurse #1 said when she got to the Resident #1's room, he/she was on the floor, seated on his/her knees between the bed and wall heater unit. Nurse #1 said she observed Resident #1 with a protrusion to his/her right leg which also appeared displaced. Nurse #1 said they (Nurse #1 and CNA #1) transferred Resident #1 from the floor onto his/her bed. Nurse #1 said Physician #1 gave the order to transfer Resident #1 to the Hospital Emergency Department for further evaluation. Review of Resident #1's Hospital Discharge Summary, dated 10/03/21, indicated Resident #1 was evaluated and treated for right leg fracture and left head contusion. Review of Certified Nurse Aide (CNA) #1's Written Statement, dated 10/02/21, indicated on 10/02/21 at 5:15 A.M., she was providing incontinent care to Resident #1 in his/her bed. The Statement indicated that she turned Resident #1 onto his/her right side and that he/she rolled over to the edge of the bed, fell off the bed, hitting the bedside dresser and the wall heater unit. During an interview on 11/05/21 at 11:04 A.M., CNA #1 said on the 10/01/21 she was assigned to care for Resident #1 on the 10:00 P.M. to 6:30 A.M. shift which went into 10/02/21. CNA #1 said she was alone providing incontinent care to Resident #1 when he/she fell off the bed onto the floor. CNA #1 said she repositioned Resident #1 onto his/her right side, facing away from her (CNA #1) and said when Resident #1 rolled over in the bed, he/she fell out on to the floor. CNA #1 said she was aware that Resident #1 required two staff members to assist with bed mobility, and providing incontinent care, but said she did not request for assistance from a second staff member before providing incontinent care to Resident #1 because the other staff members on the shift were busy. During an interview on 11/05/21 at 1:00 P.M., the Unit Manager said Resident #1 requires the assistance of two staff members with bed positioning and that his/her Plan of Care and CNA Care Cards reflected his/her level of care. The Unit Manager said CNA #1 told her she turned Resident #1 away from her in the bed during care and that she was unable to stop Resident #1 from rolling off the bed. The Unit Manager said CNA #1 did not follow Resident #1's plan of care when she provided care without the assistance of the second staff member.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls and required extensive assistance of two staff members for bed mobility and transfers, the Facility failed to ensure staff implemented interventions from his/her plan of care related to level of staff assistance required with care needs. On 10/06/21, Certified Nurse Aide (CNA) #1 provided incontinent care to Resident #1 without another staff member present to assist her. While turning Resident #1 onto his/her side, Resident #1 rolled out of bed, and fell to the floor. Resident #1 was diagnosed with right leg fracture. Findings include: The Facility's Policy titled, Quality Assurance and Performance Improvement Resident's Falls, dated 08/2019, indicated its purpose to promote resident safety and an environment free from falls to the extent possible in consideration of the resident's right to maintain autonomy and to make individual choices. Resident #1 was admitted to the Facility in July 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assist of two staff members with activities of daily living including bed mobility and incontinence care. Review of Resident #1's Plan of Care Interventions related to Decline in Functional Mobility, dated 08/23/21, indicated Resident #1 required extensive assist of two persons with bed mobility, transfers, dressing, toileting tasks, bathing and wheelchair mobility due to muscle weakness. Review of the Facility's Investigation Report, dated 10/04/21, indicated that Resident #1 was rolled out of bed during care and he/she fell on to the floor. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with fracture on his/her right leg. Review of Resident #1's Interdisciplinary Progress Note, dated 10/02/21, indicated that at 05:15 A.M., Nurse #1 was informed that Resident #1 had fallen. The Note indicated that CNA #1 was assisting Resident #1 in bed when he/she rolled off the bed. The Note indicated that Nurse #1 observed Resident #1's to have a right shin protrusion, right foot was internally rotated, and right great toe misalignment with bleeding on the edge of the toe. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for further evaluation. During an interview on 11/05/21 at 12:28 P.M., Nurse #1 said she was providing care to another resident when she heard Resident #1's bed alarm sound and heard CNA #1 yelling for help from his/her room. Nurse #1 said when she got to the Resident #1's room, he/she was on the floor, seated on his/her knees between the bed and the wall heater unit. Nurse #1 said she observed Resident #1 with a protrusion to his/her right leg which also appeared displaced. Nurse #1 said they (Nurse #1 and CNA #1) transferred Resident #1 from the floor onto his/her bed. Nurse #1 said Physician #1 gave the order to transfer Resident #1 to the Hospital Emergency Department for further evaluation. Review of Resident #1's Hospital Discharge Summary, dated 10/03/21, indicated Resident #1 was evaluated and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Certified Nurse Aide (CNA) #1's Written Statement, dated 10/02/21, indicated on 10/02/21 at 5:15 A.M., she was providing incontinent care to Resident #1 in his/her bed. The Statement indicated that she turned Resident #1 onto his/her right side and that he/she rolled over to the edge of the bed, fell off the bed, hitting the bedside dresser and the wall heater unit. The Statement indicated that she and Nurse #1 transferred Resident #1 from the floor back into his/her bed. During an interview on 11/05/21 at 11:04 A.M., CNA #1 said on the 10/01/21 she was assigned to care for Resident #1 on the 10:00 P.M. to 6:30 A.M. shift which went into 10/02/21. CNA #1 said she was alone providing incontinent care to Resident #1 when he/she fell off the bed onto the floor. CNA #1 said she repositioned Resident #1 onto his/her right side, facing away from her (CNA #1) and said when Resident #1 rolled over in the bed, he/she fell out on to the floor. CNA #1 said she was aware that Resident #1 required two staff members to assist with bed mobility, and providing incontinent care, but said she did not request for assistance from a second staff person before providing incontinent care to Resident #1 because the other staff members on the shift were busy. During an interview on 11/05/21 at 1:00 P.M., the Unit Manager said Resident #1 requires extensive assistance of two staff members with bed mobility and re-positioning. The Unit manager said Resident #1's Plan of Care and CNA Care Cards reflect his/her level of care. The Unit Manager said CNA #1 told her she turned Resident #1 away from her in bed during care and that she was unable to stop Resident #1 from rolling off the bed. The Unit Manager said CNA #1 did not follow Resident #1's plan of care when she provided care without the assistance of the second staff member.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at high risk for the development of pressure injuries, the Facility failed to ensure care and treatment to his/her actual wounds met professional standards of practice, were consistently implemented, and that nursing staff adequately monitored and assessed Resident #1's coccyx wound to determine if area was improving or deteriorating. Resident #1's coccyx area wound condition deteriorated while in Facility from a fragile area upon admission, to upon transfer and admission to the Hospital, his/her coccyx was an open wound, with bone exposed. Findings include: The Facility's Policy titled, Pressure Injury Policy, dated as revised April 2018, indicated the following: - Assessment: on admission/readmission, the licensed nurse will assess the resident's skin to identify and document existing skin areas, any dressings on the resident should be removed and skin areas assessed and documented; - the licensed nurse will implement a plan of care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - the licensed nurse will assess each resident's risk for skin breakdown by completing a Norton Plus Pressure Ulcer Scale on admission, re-admission and monthly. If the assessment identifies the resident is at risk for skin breakdown, the nurse will implement a care plan to include preventative measures; - the licensed nurse will conduct weekly assessment of pressure injuries by completing the Skin Care Treatment Sheet. The Facility's Policy titled, Preventative Skin Care Protocol, dated as revised July 2020, indicated the following: -the Facility will utilize the Norton Plus Pressure Ulcer Scale, Score of 15 or less indicates resident is severely at risk of development of pressure injuries; -all existing ulcers are to be measured and description noted in nurses notes; -the residents with alterations in skin integrity will be reviewed by the Case Management Team weekly to include a comprehensive evaluation of the condition and plan of care including current treatment, effectiveness of treatment, need to revise treatment, nutritional needs and other aspects of care potentially affecting wound healing; -ongoing assessment: all residents are to be assessed once each week by the licensed nurse during skin rounds, results of this hands-on physical skin check are to be recorded on the Resident's Treatment Record and all noted Stage 1-Stage 4 areas are to be recorded on the Skin Care Treatment Sheet; Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nurse Progress Notes related to pressure injury or wound documentation, dated 01/19/21 through 4/22/21, indicated the following: - 1/19/21, arrived at facility, dressing coccyx, no other areas noted. Review of Resident #1's admission assessments indicated there was no documentation to support nursing removed the dressing, completed an assessment of the skin under the dressing, or described baseline skin condition of coccyx. - 1/21/21, left heel red and boggy. - 1/22/21 and 1/23/21, refused dressing change to coccyx. - 1/26/21, coccyx dressing changed as ordered, no signs/symptoms of infection. - 2/04/21, coccyx fragile and excoriated, bilateral heels dry and intact. - 3/20/21, left foot up against bed and reddened area noted. - 3/21/21, buttocks with redness, bilateral feet/toes with intact abrasions, left heel with red area; Further review of Resident #1's Nurse Progress Notes, dated 01/19/21 through 4/19/21, indicated there was no documentation to support nursing staff monitored the progress toward healing of his/her wound and the effectiveness of the treatment including a description of the wound bed: color and type of tissue/character including evidence of healing (e.g., granulation tissue) or necrosis (slough or eschar); and a description of the wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) and the status of the area surrounding the wound that can be observed without removing the dressing until 4/20/21. - 4/20/21, coccyx dressing changed, old dressing with large amount of bluish/green tinged exudate. Coccyx wound is unstageable at 1.5 centimeter (cm) x 1 cm x 1 cm deep. Wound bed is 100 % slough (necrotic tissue that needs to be removed from the wound for healing to take place), periwound is red/bluish and proximal wound is 4 cm skin that is sloughing off; - 4/22/21, dressing to coccyx changed, wound is 1 cm round with a depth of 1.5 cm, tunneling 0.5 cm at 3 and 6 o'clock, undermining throughout entire wound bed, visible bone/muscle damage, Stage 4 (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Review of Resident #1's Nurse Skin Assessment Reports, dated 1/20/21 through 3/24/21, indicated the following: - 1/20/21, there was a pre-existing skin problem noted: healing coccyx wound. - 1/28/21, 2/11/21, 2/25/21, 3/11/21, 3/24/21 - there was no new or pre-existing skin problem; Review of Resident #1's Norton Plus Pressure Ulcer Scale Assessment, dated 3/31/21, indicated that Resident #1 was assessed as being at high risk for the development of pressure injuries. The Assessment indicated that Resident #1's risk factors included, poor physical condition, chair bound activity, very limited mobility, incontinence of bowel and bladder, diabetes mellitus, hypertension, abnormal blood laboratory work and five or more prescription medications. Review of Resident #1's Nurse Skin Assessment Reports, dated 4/08/21 through 4/20/21, indicated the following: - 4/08/21, there was a new or pre-existing skin problem noted: coccyx pink, feet dry, scratch to upper chest - 4/15/21, there was a new or pre-existing skin problem noted: between fingers red, feet dry, heels pink, coccyx pink. - 4/20/21, there was a new or pre-existing skin problem: Unstageable open area coccyx, 1 cm x 1.5 cm x 1 cm with purulent drainage, surrounding tissue red inflamed; feet dry, heels pink; ostomy site red. Review of Resident #1's Treatment Administration Record (TAR), dated February 2021 through April 17, 2021, indicated, he/she had a physicians order to cleanse coccyx with normal saline, pat dry and apply foam dressing every three days. Review of Resident #1's TAR, indicated there was no documentation to support that nursing adequately and consistently assessed and described his/her coccyx wound characteristics including measurements. Review of Resident #1's TAR indicated nursing only checked off the treatment as being completed, however there were no narratives or progress notes attached to the TAR, that described his/her wound condition. Further review of Resident #1's medical record indicated there was no documentation to support that nursing reviewed his/her alteration in skin integrity weekly to include a comprehensive evaluation of the condition and plan of care including current treatment, effectiveness of treatment, need to revise treatment and other aspects of care potentially affecting wound healing. Review of the Facility's Report titled Weekly Skin Analysis Summary Sheets, dated January 2021 through April 2021, indicated there was no documentation to support Resident #1's wounds were assessed during the weekly reviews conducted by the Case Management Team related to his/her alteration in skin integrity. The Report indicated Resident #1 was not added to the weekly review until 4/19/21, ( at which point his/her coccyx wound had progressed to a stage IV). This was not consistent with the Facility's Preventative Skin Care Protocol and Pressure Injury Policies. Resident #1 was transferred to the hospital on 4/25/21 and remained hospitalized at the time of the survey. Review of Resident #1's Hospital Progress Note, dated 4/26/21, indicated that Resident #1 was seen by the hospital wound nurse for his/her Stage 4 to coccyx area. The Note indicated that his/her coccyx wound was a Stage 4 pressure injury with fragments of protruding bone, mix of tan and brown slough with some flat red tissue, measuring 2.2 centimeters (cm) length by 1.5 cm width by 1.6 cm depth, with 0.6 cm undermining from 11 to 1 o'clock, peri wound area with a mix of blanching red, superficial denuded skin with 1 cm by 0.5 cm maroon intact area. Review of Resident #1's Hospital Orthopedic Surgery Progress Note, dated 4/26/21, indicated that Resident #1 presented with a new sacral decubiti and probable [CONDITION(S)] of the sacral/coccyx area. The Note indicated that Resident #1 was started on antibiotics, that surgery was indicated in the sacral/coccyx area to have the [CONDITION(S)] removed and the skin mobilized as a flap. Review of Resident #1's Hospital Progress Note, dated 4/27/21, indicated that Resident #1 was admitted to the hospital with a Stage 4 pressure injury in the coccygeal region, pathological coccygeal fracture and [CONDITION(S)] of sacrum. Review of Resident #1's Hospital Infectious Disease Progress Note, dated 4/27/21, indicated that Resident #1 had a CT scan of the pelvis on 4/25/21 which revealed a sacral decubitus ulcer with associated changes of the adjacent lower sacrum/upper coccyx suggesting [CONDITION(S)]. The CT scan indicated that the lower segment of the coccyx is slightly displaced relative to the sacrum and that the orthopedic service plans to proceed with I & D (incision and drainage and clinical lancing are minor surgical procedures to release pus or pressure built up under the skin) with flap coverage and that intravenous (IV) antibiotics were ordered. During an interview on 5/5/21 at 1:41 P.M., Nurse #1 said that Resident #1 had an open area to his/her coccyx area. Nurse #1 said she could not remember what the area looked like before it was noted as a stage 4 when he/she was transferred to the hospital. Nurse #1 said that when a treatment is done by the nurse, you should document what the wound looks like in the nurses notes or in the treatment record. Nurse #1 said that she is not allowed to stage wounds and said that the Unit Manager stages the wounds weekly during wound rounds. Nurse #1 said she could not explain why she did not describe Resident #1's wound characteristics when she changed his/her dressing and completed his/her treatment to the coccyx wound. During an interview on 5/5/21 at 2:13 P.M., the Infection Preventionist said that on 4/20/21 he was helping out on the units and said he completed the treatment to Resident #1's coccyx. The Infection Preventionist said that when he took off the dressing to Resident #1's coccyx, the dressing was saturated with greenish blue drainage and he noted a 1.5 cm opening that was covered with slough. The Infection Preventionist said he vaguely remembered that Resident #1 was admitted to the Facility with a wound to his/her coccyx. The Infection Preventionist said that the Unit Manager did weekly wound rounds on residents who had wounds. During an interview on 5/5/21 at 2:43 P.M., Nurse #2 said that Resident #1 had an open area to his/her coccyx area and had a dressing ordered to the area. Nurse #2 said she did not recall Resident #1's wound characteristics and said that there is an assessment area in the treatment record to document the wound characteristics. Nurse #2 said she could not explain why she did not document Resident #1's wound characteristics when she changed his/her dressing and completed his/her treatment to the coccyx wound. During an interview on 5/5/21 at 3:45 P.M., the Director of Nurses (DON) said that the Facility does not have a wound nurse and said that the Facility has a wound doctor who comes in weekly. The DON said that Resident #1 had a dressing on his/her coccyx area for protection. The DON said that it was her expectation that staff assess and monitor the progression of wounds when they complete the treatment and dressing change and said there should be detailed documentation in the medical record either in the treatment record or nurses notes that reflects the characteristics of wounds. The DON said that weekly wound rounds are done by the Unit Manager and wound doctor and said a weekly wound log with detailed wound characteristics is recorded on the weekly wound log. The DON said that Resident #1 was not listed on the weekly wound logs and said Resident #1 was not seen by the wound doctor because the nurses said his/her coccyx area was healed. The Surveyor attempted to interview the Unit Manager; however, the Unit Manager did not respond to the Surveyors requests to be interviewed.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent an incident of physical abuse when Nurse #1 heard Resident #1 scream, witnessed Certified Nurse Aide (CNA) #1 slap Resident #1 on the left side of his/her face, and Resident #1 stated to staff he/she was afraid of CNA #1. Findings include: The Facility Policy, titled Abuse Prevention Policies and Procedures, dated as revised 4/2017, indicated each resident has the right to be free from abuse and must not be subjected to abuse by anyone including staff. The Policy indicated that physical abuse includes hitting and slapping. Resident #1's Annual Minimum Data Set Assessment, completed 10/21/19, indicated that he/she communicated in Portuguese language and had moderate cognitive impairment. Review of the Health Care Facility Reporting System (HCFRS) Report, dated 10/27/19, indicated that at 3:10 P.M., Resident #1 stated that he/she was slapped in the face by CNA #1. The Report indicated that Nurse #1 and Resident #1 assert that the abuse happened, that CNA #1 was arrested by the police and that the allegation of physical abuse was substantiated. Resident #1's witness statement, dated 10/27/19, translated by the Human Resources Staff Member, indicated that CNA #1 hit him/her on the leg during care and then slapped him/her on the left side of his/her face. The Surveyor interviewed the Human Resources Staff Member at 11:00 [NAME]M. on 10/31/19. The Human Resources Staff Member said that Nurse #1 asked her to translate for Resident #1 who spoke Portuguese. The Human Resources Staff Member said that Resident #1 said that CNA #1 slapped his/her leg and face during care. The Human Resources Staff Member said that Resident #1 said he/she was worried that CNA #1 would return to the Facility and hurt him/her. The Surveyor interviewed Resident #1 at 11:50 [NAME]M. on 10/31/19. Resident #1 said that when he/she asked CNA #1 to pull down the bedspread, CNA #1 hit his/her leg and then slapped him/her in the face. Resident #1 said that he/she was afraid of CNA #1. Nurse #1's witness statement, dated 10/27/19, indicated she heard a scream, went to Resident #1's room and saw CNA #1 slap Resident #1 on the left side of his/her face. The Surveyor interviewed Nurse #1 at 2:08 P.M. on 10/31/19. Nurse #1 said that she heard a blood curdling scream, went to Resident #1's room, saw CNA #1 pull up Resident #1's blankets and said as CNA #1 was turning away from Resident #1, she slapped him/her on the left side of his/her face. Nurse #1 said she immediately told CNA #1 to get out of Resident #1's room. Nurse #1 said she reported the incident to the nursing supervisor and called the police. Nurse #1 said CNA #1 was arrested by the police and removed from the Facility. The Surveyor interviewed Nurse #2 at 3:00 P.M. on 10/31/19. Nurse #2 said she heard a scream and went to Resident #1's room. Nurse #2 said she saw Nurse #1 coming out of Resident #1's room and heard her tell CNA #1 to leave Resident #1's room. Nurse #2 said she heard Nurse #1 state to CNA #1 that she saw her slap Resident #1 in the face. Nurse #2 said she immediately assessed Resident #1 and asked him/her what had happened. Nurse #2, who spoke Portuguese, said Resident #1 said that CNA #1 slapped him/her on the leg and face and said Resident #1 wanted CNA #1 to leave his/her room and never come back. The Police Report, dated 10/27/19, indicated that Nurse #1 and Nurse #2 heard a scream and went to Resident #1's room. The Report indicated Nurse #1 observed CNA #1 slap Resident #1 on the left side of his/her face. The Report indicated that Resident #1 was asked what happened in Portuguese and that Resident #1 said that CNA #1 slapped him/her in the leg and face. The Report indicated CNA #1 was arrested for assault and battery on an elderly person. The Surveyor interviewed the Administrator at 3:15 P.M. on 10/31/19. The Administrator said the allegation of physical abuse involving CNA #1 was substantiated by the Facility.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure residents were free from incidents of verbal abuse, when staff members witnessed Certified Nurse Aide (CNA) #1 say to Resident #1, words to the effect of , you're a pain in my ass and you can pee where you are. Resident #1 became upset by the remarks. Findings Include: The Facility's Abuse Prevention Policies and Procedures, dated 04/2017, indicated that: -Each Resident has the right to be free from abuse, neglect, misappropriation of his/her property -Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families -Willful means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Resident #1 was admitted to the Facility in 07/2018, [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) Assessment, dated 07/13/18, indicated that Resident #1 had severe cognitive impairment and required extensive assistance from staff for incontinent care. Resident #1's Plan of Care, dated 10/05/18, indicated Resident #1 was incontinent and required two staff members to assist with toileting tasks. The Facility's Internal Investigation, dated 07/06/18, indicated the Facility received a statement at 11:30 A.M. on 07/03/18 from Certified Nurse Aide (CNA) #3, indicating that she had witnessed CNA #1 say to Resident #1, words to the effect of You're a pain in my ass and that CNA #1 had refused to assist Resident #1 to the bathroom. CNA #3's Written Statement, dated 07/03/18, indicated she witnessed CNA #1 say to Resident #1 that she would not toilet him/her and said to Resident #1 you're a pain in my ass or words to that effect. The Statement indicated that CNA #1 then heard CNA #1 say that she did not want to be written up again if Resident #1 fell . The Statement indicated that Resident #1 cried after the exchange with CNA #1. CNA #4's Written Statement, dated 07/03/18, indicated she witnessed CNA #1 refuse to provide incontinent care to Resident #1. The Statement indicated Resident #1 was crying to go to the bathroom. The Statement indicated CNA #1 said to Resident #1 words to the effect of, I'm not going to take you, I have already been in trouble one time and I don't want to be again. You can't stand by yourself and I'm not going to break my back. You can go where you are. CNA #1's Written Statement, dated 07/03/18, indicated that she told Resident #1 that she was unable to change him/her until they are finished with lunch. The Statement indicated that Resident #1 was unable to be put on the toilet for care, as he/she had previously fallen while CNA #1 assisted Resident #1 on and off the toilet; therefore, Resident #1 now required that incontinent care be provided while he/she was in bed. Surveyor interviewed CNA #1 at 11:50 A.M. on 10/05/18. CNA #1 said Resident #1 asked for assistance to use the bathroom when staff were passing out lunch trays. CNA #1 said that staff are not supposed to assist residents with incontinent care or assist them to use the toilet, due to concerns of cross contamination. CNA #1 said that Resident #1 had fallen once before while she was assisting Resident #1 to use the toilet. CNA #1 said after Resident #1's last fall, she would only change Resident #1's brief for incontinent care and would not toilet him/her. The Facility provided the Department with a Plan of Correction which addressed the concerns as evident by: 1. Corrective actions accomplished by the Facility for those residents found to have been affected by the deficient practices cited; A. The employee was suspended and subsequently terminated on (MONTH) 6, (YEAR), having no further contact with residents. B. The affected residents were interviewed on, 7/05/18 and 7/06/18, and followed by social services to identify any ongoing need for support. 2. Identifying other residents having the potential to be affected by the same deficient practices and what corrective action will be taken: A. The Director of Social Services conducted random resident interviews between the dates of 7/05/18 and 7/06/18 to identify any additional potentially affected residents. B. Forty-Seven percent of all residents on the floor were interviewed. No other affected residents were identified. C. Staff interviews were conducted with any staff member who worked on the floor for the previous seven days (of the alleged incident) to identify whether they had witnessed any other inappropriate staff and resident interactions. No other inappropriate interactions were reported. 3. Measures put into place and/or systemic changes made by the Facility to ensure that the deficient practices do not re-occur: A. The entire facility staff were educated on abuse observation, identification and reporting requirements. B. Education took place between (MONTH) 3, (YEAR) and (MONTH) 19, (YEAR), and was conducted by the following: RN Consultant, Assistant Director of Nursing, Dementia Specialty Care Unit Manager, Evening Supervisor, and Dementia Specialty Care Unit Activity Director C. Monthly Facility audits were conducted on Staff and Resident Interactions to assess the appropriateness of those encounters. These audits began (MONTH) 11, (YEAR) and continue to be conducted monthly at present. Audits were conducted by the following staff members: Executive Director, HR Generalist, and Housekeeping Supervisor D. Monthly Facility audits were conducted to evaluate appropriateness of Care Delivery. These audits began (MONTH) 10, (YEAR) and continue to be conducted monthly at present. Audits were conducted by the following staff members: Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator 4. Corrective actions will be monitored to ensure the deficient practices will not re-occur. A. The Director of Nursing is responsible for maintaining continued compliance. The Director of Nursing or designee will present and review audit findings at the Quarterly Quality Assurance and Performance Improvement (QAPI) meeting.

Based on record review, interviews and video review, the Facility failed to ensure that one of three sampled Residents (#1) was free of physical restraint for staff convenience. On Saturday, 9/20/14 at 6:08 P.M., Certified Nurse Aide (CNA) #1 sat Resident #1 in a wheelchair in the unit hallway - for the third time in eight-minutes - and placed her (CNA #1's) gait belt around Resident #1's abdomen and the back of the wheelchair seat effectively preventing Resident #1 from being able to rise from the wheelchair. After 10-minutes of being restrained, when Resident #1 got the gait belt off over his/her head and his/her chair alarm sounded, CNA #2 approached Resident #1 and reapplied the gait belt to Resident #1 and the wheelchair seat effectively preventing Resident #1 from rising again. Findings included: Resident #1 resided at the Facility for three-days when the incident occurred. Resident #1 had a legal guardian. Resident #1's [DIAGNOSES REDACTED]. Resident #1 did not have a physician's orders [REDACTED]. The Surveyor reviewed the Facility's surveillance video that contained footage (camera #22) between 6:00 P.M. and 6:22 P.M. on 9/20/14 which clearly showed Resident #1 ambulating on the unit until CNA #1 led him/her to sit in a wheelchair located at the junction of the unit's two hallways. The video showed that when CNA #1 walked away from him/her, Resident #1 rose from the wheelchair seat twice between 6:02 P.M. and 6:07 P.M. and walked away from the area. The video showed CNA #1 returned Resident #1 to the wheelchair and reseat him/her each time. The video surveillance demonstrated that at 6:08 P.M., CNA #1 again returned Resident #1 to the wheelchair seat and fastened her gait belt around Resident #1's waist and the back of wheelchair seat effectively preventing Resident #1 from being able to rise. The Surveyor interviewed CNA #1 at 12:50 P.M. with a Union representative present per CNA #1's request. CNA #1 denied ever placing her gait belt around Resident #1 and the the back of the wheelchair seat so that Resident #1 could not keep getting up and walking around. CNA #1 said that she put the gait belt around Resident #1's waist only so that if or when he/she next stood and walked away, staff could grasp the gait belt to keep Resident #1 steady on his/her feet and return him/her to a seat. CNA #1 said that after she placed the gait belt around Resident #1's waist (only) for the third time, Resident #1 did not stand-up again. The video surveillance demonstrated that Resident #1 responded to being restrained by repeatedly leaning forward, seemingly a motion that would precede standing, but did not stand. The video also demonstrated Resident #1 repeatedly fiddled with and touched the gait belt at his/her waist. The video footage showed that at about 6:18 P.M., CNA #2 responded to Resident #1's position in the hallway because Resident #1 had been able to get the gait belt off over his/her head and stood up. The video footage showed Nurse #1 turn toward Resident #1 and take the gait belt from Resident #1 and hand it to CNA #2. The video showed CNA #2 reapply the gait belt to Resident #1 and the wheelchair seat effectively preventing Resident #1 from rising. The Surveyor interviewed CNA #2 at 1:08 P.M. on 10/2/14. CNA #2 adamantly denied ever restraining Resident #1 in the wheelchair with a gait belt. CNA #2 said she approached Resident #1 at one point after supper when Resident #1 was sitting in the wheelchair and found a gait belt loose on the wheelchair, but not on Resident #1. CNA #2 said she asked whose gait belt it was and CNA #1 said it was hers. CNA #2 said she gave the gait belt to CNA #1 and wheeled Resident #1 down the hallway to get him/her ready for bed. The video footage does not corroborate CNA #2's version of events. The video footage showed CNA #3 and CNA #2 together beside Resident #1 exchanging some words right after CNA #2 reseated Resident #1 and applied the gait belt as a restraint. The video demonstrated Resident #1 remained restrained in the wheelchair for just under four more minutes until CNA #2 arrives, releases the gait belt, gives it to CNA #1 and wheels Resident #1 in the direction of his/her room. The Surveyor interviewed CNA #3 at 3:55 P.M. on 10/2/14. CNA #3 said that she observed ,the CNA she thought was CNA #1, apply the gait belt around Resident #1 and the wheelchair seat. CNA #3 said she told CNA #1 she thought CNA #1 should not be doing that as it (restraining a resident with a gait belt) was not allowed. CNA #3 said CNA #1 responded by saying words to the effect of, "What are we supposed to do, he/she won't stop getting up." The Surveyor's review of the video of what CNA #3 described above, showed that CNA #3 was not near CNA #1 and Resident #1 when CNA #1 placed her gait belt around Resident #1 and the wheelchair seat back. The video footage did show that CNA #3 was near to and spoke with CNA #2 when CNA #2 applied the gait belt around Resident #1's waist and the wheelchair as a restraint. CNA #3 said she did not bring the actions of CNA #1 to Nurse #1's attention even though Nurse #1 was nearby, but told the Surveyor she did not know how Nurse #1 could have been so close to where Resident #1 was restrained in the wheelchair, and not been aware of what was happening. The Surveyor interviewed Nurse #1 at 9:47 A.M. on 10/8/14. Nurse #1 said that she saw Resident #1 seated in a wheelchair in the hallway with a gait belt on, but did not think there was anything wrong with it. Nurse #1 said she did not know that Resident #1 was restrained in the wheelchair by the gait belt. Nurse #1 said she never saw any CNA put the gait belt around Resident #1 and the back of the seat of the wheelchair as a restraint. In total, Resident #1 was restrained in the wheelchair for just under 13 minutes. The day after the incident at about 3:00 P.M. the Facility became aware of the incident and Resident #1 received a complete body check from nursing. Resident #1's nurse found he/she sustained no physical injury, marks, redness from the incident.