Every finding on record at Care One at Brookline

Based on observation, record review and interview, the facility failed to maintain a dignified existence for four Residents (#4, #20, #116 and #6) out of a total sample of 25 residents. Specifically,For Residents #4 and #20 the facility failed to maintain a dignified experience during meals by leaving the tray in front of the Resident for an extended period of time before providing assistance and standing over the Resident while assisting with the meal.For Resident #116 the facility failed to ensure that the Resident's chest was not visible from the hallway.For Resident #6 the facility failed to ensure that the Resident's privacy was maintained when their brief was visible from the hallway.Findings include:Review of facility policy titled Dignity, dated as revised February 2021, indicated the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self- worth and self- esteem.-Residents are treated with dignity and respect at all times.-Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures 1a. Resident #4 was admitted to the facility in October 2025 with diagnoses that included osteomyelitis and dysphagia (difficulty swallowing). Review of Resident #4's most recent Minimum Data Set (MDS), dated [DATE], indicated that the Resident was not able to participate in the Brief Interview for Mental Status exam and was assessed by staff has exhibiting moderately impaired cognitive skills for daily decision making. The MDS further indicated that the Resident is dependent for eating. On 12/16/25 at 8:18 A.M., the surveyor observed the Resident in bed. A staff member assisting the Resident with breakfast. The staff member was standing next to the bed, over the Resident assisting with the meal. On 12/17/25 at 11:53 A.M., the surveyor observed the Resident in bed with his/her eyes closed. The lunch tray had been passed to the Resident prior to the surveyor's arrival, and was on the over bed table, out of reach of the Resident. On 12/17/25 at 12:00 P.M., the surveyor observed a Certified Nurses' Aide (CNA) enter the room and begin to assist the Resident with his/her lunch meal. The CNA stood next to the bed, standing over the Resident to assist with the meal. During a continuous observation on 12/18/25 from 7:55 A.M., to 8:07 A.M., the surveyor observed a staff member bring the breakfast tray into the Resident's room and leave it on the over bed table, out of reach of the Resident. The Resident was observed to be awake in bed. For the duration of this observation, no staff entered the room to assist the Resident with his/her breakfast. 1b. Resident #20 was admitted to the facility in October 2025 with diagnoses that included metabolic encephalopathy and dysphagia (difficulty swallowing) oral phase. Review of the Minimum Data Set (MDS) Assessment, dated 10/20/25, failed to indicate a cognitive status was assessed for Resident #20. The MDS further indicated that the Resident required partial/ moderate assistance for eating meals. Review of Resident #20's current Activities of Daily Living (ADL) care plan, dated 10/21/25, indicated the following:-ADL Self- care deficit related to physical limitations.-Interventions included: Assist of (Specify: 1person/2 person) with ADL's. On 12/16/25 at 8:08 A.M., the surveyor observed Resident #20 sitting up in bed. A staff member was assisting the Resident with eating the breakfast meal while standing next to the bed, over the Resident. The staff member stood with her hand on her hip while assisting the Resident. On 12/16/25 at 12:18 P.M., the surveyor observed Resident #20 in bed. The Resident's lunch tray was on the over bed table, covered and not set up. The meal had been brought into the Resident's room before the surveyor arrived on the unit. On 12/16/25 at 12:27 P.M., a staff member entered the Resident's room and began to assist the Resident with his/her meal. The staff member stood on the side of the Resident's bed, over the Resident and stood with her hand on her hip while she assisted the Resident with the meal. During an interview on 12/18/25 at 8:55 A.M., Nurse #3 said that staff should be assisting the residents immediately upon providing a meal tray to them. She said it should not be left in the room to get cold. She further said that staff should be sitting with residents while assisting them with their meals. She said staff should be at eye level and not standing over them. During an interview on 12/18/25 at 10:01 A.M., Certified Nurses' Aide (CNA) #1 said that staff should be sitting and at eye level with residents that they are assisting with meals and no one should be standing over a resident while assisting them. During an interview on 12/18/25 at 10:09 A.M., Director of Nurses #1 and Director of Nurses #2 said that staff should be sitting to assist residents with their meals. They said that staff should assist the resident slowly without rushing them. They further said that staff should not be bringing the meals into the residents until they are ready to sit and assist them as the meals could get cold. They said that they would expect that staff are providing a dignified dining experience. 2. Resident #116 was admitted to the facility in December 2025 with diagnoses that included history of falling and muscle weakness. There is no Minimum Data Set (MDS) information for Resident #116. Review of the medical record failed to indicate any behaviors were present or monitored for Resident #116. Review of Resident #116's active care plan failed to indicate any behaviors that were present or being monitored by staff. On 12/16/25 at 9:07 A.M., the surveyor observed Resident #116 sleeping in bed without clothing, with a sheet only up to his/her waist. The Resident's chest was visible from hallway. On 12/17/25 at 8:41 A.M., the surveyor observed the Resident sitting up in bed awake. The Resident only had a brief on and had removed his/her johnny. The Resident's chest was visible from the hallway. The Resident's breakfast tray was set up in front of him/her. Resident #116 is unable to participate in an interview. During an interview on 12/18/25 at 8:55 A.M., Nurse #3 said that a resident's chest should not be visible to people from the hallway, as that would not be dignified for the resident. During an interview on 12/18/25 at 10:01 A.M., CNA #1 said that residents should not be visible from the hallway if they are exposed in any way. She said a curtain should be pulled to maintain dignity. During an interview on 12/18/25 at 10:09 A.M., Director of Nurses #1 and Director of Nurses #2 said that a resident's chest visible to people in the hallway would not be dignified for a resident and if it is a behavior then it should be addressed by the staff. 3. Resident #6 was admitted to the facility in October 2025 with diagnoses that included adult failure to thrive and major depressive disorder. Review of Resident #6's most recent Minimum Data Set (MDS) Assessment, dated 12/7/25, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of Resident #6's active Activities of Daily Living (ADL) care plan indicated the following:-Assist of 1 staff with daily hygiene, grooming, dressing, oral care and eating, dated 12/2/25. Further Review of the Resident's care plan failed to indicate any behaviors exhibited by the Resident. On 12/16/25 at 8:58 A.M., the surveyor observed from the hallway the resident lying awake in bed. The Resident was wearing a t-shirt and a brief only, which was visible from the hallway. On 12/16/25 at 9:55 A.M., the surveyor observed from the hallway the Resident sitting on the side of the bed wearing only a brief that was visible from the hallway. The Resident had a basin of water on his/her bedside table. On 12/17/25 at 6:56 A.M., the surveyor observed the Resident lying in bed, uncovered, wearing a johnny and a brief. The Resident was uncovered, and his/her brief was visible from the hallway. On 12/17/25 at 9:24 A.M., the surveyor observed the Resident lying in bed, uncovered, wearing a johnny and a brief. The Resident was uncovered, and his/her brief was visible from the hallway On 12/18/25 at 10:46 A.M., Resident #6 was sleeping and unavailable at this time for an interview. During an interview on 12/18/25 at 8:55 A.M., Nurse #3 said that a resident wearing a brief should not be visible from the hallway, and the brief should not be exposed for others to see. She said the resident's privacy and dignity should be maintained. During an interview on 12/18/25 at 10:01 A.M., CNA #1 said that residents should not be visible from the hallway if they are exposed in any way, including when they are utilizing a brief that could be visible to others and privacy should be maintained. During an interview on 12/18/25 at 10:09 A.M., Director of Nurses #1 and Director of Nurses #2 said that a resident utilizing a brief should be covered to maintain privacy with either clothing or a sheet or blanket. They said that Resident #6 does not like to have his/her privacy curtain pulled, but a sheet should be provided for privacy and dignity, and a resident's brief should not be visualized from the hallway.

Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#88, #68 and #14) out of sample of 25 residents. Specifically,For Resident #88 the facility failed to properly label and store respiratory supplies and failed to administered oxygen as per the physician's orders.For Resident #68 and Resident #14 the facility failed to properly label and store respiratory supplies.Findings include:Review of facility policy titled Oxygen Administration, dated as revised October 2010, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. 1. Resident #88 was admitted to the facility in October 2025 with diagnoses that included acute respiratory failure and chronic obstructive pulmonary disease.Review of Resident #88's most recent Minimum Data Set (MDS) Assessment, dated 12/11/25, indicated a Brief Interview for Mental Status score of 13 out of a possible 15, indicating intact cognition. The MDS further indicated the use of oxygen therapy.On 12/16/25 at 9:52 A.M., the surveyor observed the Resident sleeping in bed. The Resident was receiving oxygen via nasal cannula at 4.5 liters per minute (lpm). The oxygen tubing was not labeled with a date, and the nebulizer was not stored in a bag and was observed in the drawer of the bedside table with other belongings.On 12/17/25 at 6:50 A.M., the surveyor observed the Resident in bed, receiving oxygen via nasal cannula at 4.5 lpm. The nebulizer was not stored in a bag and was observed in the Resident's bed.On 12/18/25 at 6:52 A.M., the surveyor observed the Resident awake in bed, receiving oxygen via nasal cannula at 4.5 lpm. The concentrator was out of reach of the Resident.On 12/18/25 at 8:47 A.M., the surveyor observed the Resident awake in bed, receiving oxygen via nasal cannula at 4.5 lpm. The concentrator was out of reach of the Resident, and the Resident said he/she had not changed the setting on the concentrator.Review of Physician's orders indicated the following:-Oxygen at: 2 Liters/minute Via: Nasal Cannula, dated 12/6/25.-(Continuous/PRN) Oxygen Therapy Oxygen at: 2 Liters/minute Via: Via: Nasal Cannula, dated 12/6/25.-Change all disposable oxygen supplies every week and as needed. Label and date all supplies, every night shift, every Wednesday, dated 12/6/25.Review of nursing progress notes indicated the following:-A progress note dated 12/14/25, that indicated in part: Pt (patient) on 4L (liters) nasal cannula with SATs 97%.-A progress note dated 12/11/25, that indicated in part: Pt on 2L nasal cannula and O2 SATs 90-91%. Pt was then turned to 4L nasal cannula and is starting 95%. Vitals were WNL (within normal limits). But O2 was low and raised to 4L with positive refiled. [sic]Review of Resident #88's active respiratory care plan, dated 12/5/25, indicated the following:-Administer oxygen per physician's orders.During an interview on 12/18/25 at 8:51 A.M. Nurse #3 said that all respiratory supplies should be changed weekly and labeled with a date. She further said that any supplies not in use at any time should be stored in a plastic bag to prevent exposure to germs or the growth of bacteria. Nurse #3 said that any oxygen being administered should be administered per physician's orders. She said Resident #88 should be on 2 lpm as per physician's orders and receiving oxygen at 4 lpm places the Resident at risk for potential elevation in carbon dioxide levels. During an interview on 12/18/25 at 10:04 A.M., Director of Nurses #1 and Director of Nurses #2 said that when respiratory equipment is not in use it should be stored in a bag. They further said all disposable equipment should be changed and labeled weekly and as needed. They further said that oxygen should be administered as per the physician's orders and should not be turned to a higher flow rate without physician notification and obtaining a new order for administration. She said Resident #88 would not be able to change the concentrator flow rate him/herself.2a. Resident #68 was admitted to the facility in November 2025 with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure.Review of Resident #68's most recent Minimum Data Set (MDS) Assessment, dated 12/5/25, indicated a Brief Interview for Mental Status score of 14 out of a possible 15, indicating intact cognition. Review of Resident #68's active physician's orders indicated the following:-Change and label nebulizer tubing every week and as needed, every night shift every Monday and as needed, dated 12/1/25.On 12/16/25 at 8:59 A.M., the surveyor observed the Resident's nebulizer machine on the over bed table. The tubing and pipe connected to the machine were not labeled with a date and the pipe was stored on the bedside table, not in a bag.On 12/17/25 at 6:54 A.M., the surveyor observed the nebulizer laying on the overbed table, not stored in a bag.During an interview on 12/17/25 at 6:54 A.M., Resident #68 said that staff changed the tubing and labeled it yesterday because it was not labeled and it was weak and kept popping off the top of the nebulizer machine. He/She said he/she wasn't sure when it was changed last before yesterday.On 12/18/2025 at 6:56 A.M., the surveyor observed the nebulizer laying on the overbed table, not stored in a bag. 2b. Resident #14 was admitted to the facility in November 2025 with diagnoses that included cerebral infarction, chronic respiratory failure and dysphagia.Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/2/25, indicated the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff as having severe cognitive impairment. The MDS further indicated the Resident required suctioning and tracheostomy care.On 12/16/25 at 8:04 A.M., the surveyor observed Resident #14 lying in bed sleeping. The Resident had a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea). Respiratory supplies were stored in the open on the Resident's bedside table. There was a nebulizer with tubing that was not labeled with a date and was not stored in a bag but was out on the bedside table. Suction tubing and a Yankaur (a firm plastic suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction without damaging surrounding tissue. This tool is used to suction pharynx secretions in order to prevent aspiration) were unlabeled and not stored with any type of covering or protection.During an interview on 12/18/25 at 8:51 A.M. Nurse #3 said that all respiratory supplies should be changed weekly and labeled with a date. She further said that any supplies not in use at any time should be stored in a plastic bag to prevent exposure to germs or the growth of bacteria. During an interview on 12/18/25 at 10:04 A.M., Director of Nurses #1 and Director of Nurses #2 said that when respiratory equipment is not in use it should be stored in a bag. They further said all disposable equipment should be changed and labeled weekly and as needed.

Based on observation and interview, the facility failed to ensure medications and biologicals were secured on two out of three Resident units. Specifically, medication carts were unlocked on the first floor and second floor. Findings include:Review of the facility policy titled Medication Labeling and Storage dated revised February 2023 indicated that compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. On 12/16/25 at 7:00 A.M., the surveyors observed two medication carts on the first-floor unit unlocked, and no nurses present within eyesight of the medication carts. 2. On 12/16/25 at 3:27 P.M., the surveyor observed an unlocked medication cart on the second-floor unit. The surveyor also observed other staff members and residents in the hall in close proximity to the unlocked medication cart. The surveyor then observed Nurse #1 enter the second-floor unit carrying a bag of takeout food and several drinks. During an interview on 12/16/25 at 3:27 P.M., Nurse #1 said that she had left the medication cart unlocked when she went down to the first floor to pick up the takeout food and drinks. Nurse #1 said that she should have locked the medication cart before leaving the floor. During an interview on 12/17/25 at 10:25 A.M., Corporate Nurse #1 said that medication carts are to be locked at all times, and the nurse should have locked the cart prior to leaving the unit.

Based on observations and interviews, the facility failed to provide a homelike environment during dining on one of three Resident units. Specifically, on the second-floor unit, residents were observed eating meals on meal trays in the dining room.Findings include:Review of the facility policy titled Homelike Environment, dated revised February 2021, failed to indicate that meals are served in a homelike manner. On 12/16/25 at 8:45 A.M., the surveyor observed 4 out 4 residents in the second-floor dining room eating breakfast served on trays. On 12/16/25 at 1:10 P.M., the surveyor observed 3 out of 4 residents in the second-floor dining room eating lunch served on trays. On 12/17/25 at 8:55 A.M., the surveyor observed 4 out of 4 residents in the second-floor dining room eating breakfast served on trays. On 12/17/25 at 12:57 P.M., the surveyor observed 4 out of 4 residents in the second-floor dining room eating lunch served on trays. One resident was being assisted by staff On 12/18/25 at 8:47 A.M. the surveyor observed 3 out of 3 residents in the second-floor dining room eating breakfast served on trays. One resident was being assisted by staff.During an interview on 12/18/25 at 9:50 A.M., Director of Nursing #2 said that meals are not supposed to be served off of trays.

Based on record review and interview, the facility failed to implement a care plan for one Resident (#2) out of a total sample of 25 residents. Specifically, for Resident #2, the facility failed to implement a care plan for a knee immobilizer.Findings include:Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated revised March 2022 indicated that the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #2 was admitted to the facility in April 2025 with diagnoses including non-displaced fracture of the right tibial tuberosity, brain cancer and malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #2 is severely cognitively impaired and totally dependent on staff for all activities of daily living. Review of the physician's orders dated December 2025 indicted an order dated to start 11/12/25 for Right Knee Immobilizer: Check skin integrity every shift. Review of the current care plan indicated a focus of; At risk for complications due to musculoskeletal problems related to fracture right tibial fracture related to fall. Date Initiated: 11/11/2025 Revision on: 11/13/2025 with an intervention of immobilizer as ordered. On 12/16/25 at 10:00 A.M., and 2:00 P.M., the surveyor observed Resident #2 lying in bed and the knee immobilizer on a stool, leaning on the wall, across the room. On 12/17/25 at 10:20 A.M., 12:30 P.M. and 2:45 P.M., the surveyor observed Resident #2 lying in bed and the knee immobilizer on a stool, leaning on the wall, across the room. Review of the progress notes dated December 2025 failed to indicate Resident #2 refused to wear the brace or that the physician was notified. During an interview on 12/18/25 at 7:25 A.M., Nurse #2 said that nurses are to follow physician orders and the knee immobilizer should have been placed on the Resident as ordered. Nurse #2 then said that if a resident were to refuse a physician's order, the nurse should document the refusal, write a progress note, and call the physician. During an interview on 12/18/25 at 7:27 A.M., Director of Nursing (DON) #1 said that nurses are to follow a physician's orders and the care plan at all times. DON #1 then said that should a resident refuse a physician's order, then the medical record should reflect the refusal and the physician notification.

Based on record review and interviews, the facility failed to address recommendations from the dialysis center. Specifically, the facility failed to notify the physician of dialysis recommendations for one Resident #10 out of a sample of 25 Residents.Findings include: A review of the facility policy titled 'Hemodialysis Pre and Post Care' with a revision date of March 2010 indicated the following:-Residents will receive appropriate care and monitoring pre and post dialysis.-To assist the residents/patient in maintaining homeostasis pre and post hemodialysis.-Document all communications in the hemodialysis communication progress note or Dialysis center communication book.-Ensure ongoing communication with dialysis center staff.Resident #10 was admitted to the facility in July 2017 with diagnoses including end stage renal disease and dependence on renal dialysis.A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMs) score of 0/15 indicating severe cognitive impairment.A review of the dialysis progress notes filed in the dialysis communication book dated 12/16/25 indicated the following:30 day supply of sevemar carbonate (a medication used to control high blood phosphate levels) provided. Please make sure the resident gets the medication with each meal for phosphate control. Please call dialysis to acknowledge the reception of the medicine. [sic]A review of the medical record failed to indicate that that the physician had been contacted to approve or deny this recommendation.During an interview and record review on 12/18/25 at 8:37 A.M., Unit Manager # 1 and the Surveyor reviewed the medical record. The Unit manager said the dialysis recommendation to include sevemar carbonate in the Resident's current medications had not been addressed. The Unit Manager said the Nurse is supposed to review the dialysis communication book after the Resident returns from dialysis. The Unit Manager said the Nurse is then supposed to contact the physician immediately for approval or denial of any recommendations made in the dialysis communication book.During an interview on 12/18/25 at 9:00 A.M., Director of Nurses #1 and #2 said the dialysis book should be reviewed by Nurses after residents return from dialysis. DON #1 and #2 said the physician should have been contacted to approve or deny sevemar carbonate promptly, within 24 hours.

Based on record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#14, #10 and #2) out of a total sample of 25 Residents. Specifically,For Resident #14, the medical record failed to accurately indicate necessary care to be provided to a tracheostomy tube.For Resident #10, the facility failed to accurately document blood pressure taken.For Resident #2 the facility failed to a. document accurately for the application of a knee brace and, b. accurately document a treatment.Findings include: 1. Resident #14 was admitted to the facility in November 2025 with diagnoses that included cerebral infarction, chronic respiratory failure and dysphagia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/2/25, indicated the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and was assessed by staff as having severe cognitive impairment. The MDS further indicated the resident required suctioning and tracheostomy care. Review of physician's orders indicated the following: -Trach care every shift (clean non-disposable inner cannula, around stoma and under flange of trach with sterile water, and change 4x4 gauze drainage sponge), every shift, dated 11/27/25. -If inner cannula is disposable, change every day and as needed, dated 11/27/25 Review of the December 2025 Treatment Administration Record (MAR) indicated the following: -Daily from 12/1 through 12/17 staff signed off changing the disposable cannula daily. -Every shift from 12/1 through 12/17 staff signed off trach care and cleaning of a non-disposable inner cannula. On 12/16/25 at 8:04 A.M., the surveyor observed Resident #14 sleeping in bed. A tracheostomy was in place. During an interview on 12/18/25 at 9:03 A.M., Nurse #4 said she regularly cares for Resident #14. She is not sure if the cannula is disposable or not for Resident #14's trach. She said she doesn't clean a cannula but just cleans around the outside of the trach and re applies a drain sponge around it. She said the orders are not clear. During an interview on 12/18/25 at 10:18 A.M., Director of Nurses #1 and Director of Nurses #2 said that the type of trach that Resident #14 has does not have an inner cannula at all. They said physician's orders should be more specific as to the care required for each resident. 2. A review of the facility policy titled 'Hemodialysis Pre and Post Care' with a revision date on March 2010 indicated the following: -Do not use access arm for venipuncture or blood pressure. A review of the facility policy titled 'Charting and Documentation' with a revision date of July 2017 indicated the following: -Documentation in the medical record will be objective, (not opinionated or speculative), complete, and accurate. Resident #10 was admitted to the facility in July 2017 with diagnoses including end stage renal disease and dependence on renal dialysis. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMs) score of 0/15 indicating severe cognitive impairment. A review of Resident #10's December 2025 physician's orders indicated the following: -No BP (blood pressure) or draw on left arm. [sic] A review of Resident #10's blood pressure documentation indicated the following: -12/13/25 10:22 144/89 mmHg (millimeters of mercury) Lying l/arm. [sic] -12/13/25 10:25 144/89 mmHg (millimeters of mercury) Lying l/arm. [sic] During an interview and medical record review on 12/18/25 at 8:37 A.M., Unit Manger #1 and the Surveyor reviewed the medical record. The Unit Manager said Nurses should not be taking blood pressures on the Resident's left arm as per the physician's orders. The Unit Manager said the Nurses must have documented inaccurately. The Unit Manager said the Nurses should document accurately in the medical record. During an interview on 12/18/25 at 9:00 A.M., the Director of Nurses #1 and #2 said Nurses should not be taking blood pressure on the Resident's left arm. DON #2 said since the AV fistula (Arteriovenous Fistula) is still working well with no infections, she said she is sure the Nurses documented in the medical record inaccurately. DON #2 said Nurses should document accurately in the medical record. 3. Resident #2 was admitted to the facility in April 2025 with diagnoses including non-displaced fracture of the right tibial tuberosity, brain cancer and malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #2 is severely cognitively impaired and totally dependent on staff for all activities of daily living. a. Review of the physician's orders dated December 2025 indicted an order dated to start 11/12/25 for Right Knee Immobilizer: Check skin integrity every shift. Review of the current care plan indicated a focus of; At risk for complications due to musculoskeletal problems related to fracture right tibial fracture related to fall. Date Initiated: 11/11/2025 Revision on: 11/13/2025 with an intervention of immobilizer as ordered. On 12/16/25 at 10:00 A.M., and 2:00 P.M., the surveyor observed Resident #2 lying in bed and the knee immobilizer on a stool, leaning on the wall, across the room. On 12/17/25 at 10:20 A.M., 12:30 P.M. and 2:45 P.M., the surveyor observed Resident #2 lying in bed and the knee immobilizer on a stool, leaning on the wall, across the room. Review of the progress notes dated December 2025 failed to indicate Resident #2 refused to wear the brace. Review of the Treatment Administration Record indicated that on 12/16/25 the nurses documented that the knee immobilizer was on, on all three shifts. Review of the Treatment Administration Record dated 12/17/25 indicated that the nurse documented that the knee immobilizer was on. b. On 12/17/25 at 10:55 A.M., the surveyor observed Nurse #5 perform a treatment to Resident #2's right leg. Review of the Medication Administration Record dated 12/17/25 at 8:21 A.M., indicated that nurse #5 had signed off that the treatment had been completed. During an interview on 12/18/25 at 7:25 A.M., Nurse #2 said that if a resident were to refuse a physician's order the nurse should document the refusal, write a progress note and call the physician. Nurse #2 said that a nurse should never document that a physician's order was completed when it was not. During an interview on 12/18/25 at 7:27 A.M., Director of Nursing (DON) #1 said that nurses are to accurately document in the medical record. DON #1 then said that a nurse should never document that a treatment was completed before the completion of the treatment.

Based on record review and interview, the facility failed to ensure that concerns addressed by the Resident Council Group had sufficient follow-up to address and prevent recurrence. Findings include: Review of the facility policy, Resident Council, dated as revised February 2021, indicated the facility supports residents' rights to organize and participate in the resident council. 1. The purpose of the resident council is to provide a forum for: a. residents, families, and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; and d. disseminating information and gathering feedback from interested residents. 6. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items of concern. Review of the facility policy, Menus, undated, indicated that menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Review of the facility policy, Grievances/Complaints, Recording and Investigating, dated as revised 4/12/18, indicated all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer. 2. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations. 3. The department directors of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway. 5. The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. 6. The Resident Grievance/Complaint Investigation Report Form will be filed with the Administrator within five (5) working days of the incident. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within five (5) working days of the filing of the grievance or complaint. 8. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect, and misappropriation of property, as per state law. During an initial tour of the facility kitchenettes on 11/19/24, the surveyor observed three out of three kitchenettes without condiments such as creamers, butter, salt, and pepper. During an interview on 11/19/24 at 8:22 A.M., Resident #351 said his/her biggest complaint is that he/she is unable to get condiments when he/she asks for them. The Resident said if he/she asks for creamer or ketchup staff are unable to give them anything because the staff say they have none to give. During the Resident Group interview on 11/20/24 at 1:25 P.M., six residents were in attendance and reported the following: - 6 of 6 Residents said menus are not followed as posted. Sometimes they receive potatoes and rice at the same meal and the meal is too starchy. - 5 of 6 Residents said they often do not get condiments on meal trays, such as salt, pepper, sugar, butter, or creamers. The Residents said that often they must wait upwards of 30 minutes for nursing to provide condiments and their hot foods are no longer hot, such as coffee that needs creamers and toast that needs butter, and this diminishes the dining experience. The Residents said that this concern comes up month after month and the residents do not feel that the facility has sufficiently responded to their concerns. Review of the Resident Council Minutes, dated 8/8/24, indicated the following concerns: Dietary: - Kitchenettes are not stocked sometimes. - Residents not receiving the condiments he/she wants. - Menu choices not followed. - Slips don't match trays. - Missing condiments. Review of the Resident Council Minutes, dated 9/12/24, indicated the following concerns: Dietary: - Residents not receiving condiments. - Residents not receiving preferred meal choices. Review of the Resident Council Minutes, dated 10/23/24, indicated the following concerns: Dietary: - No condiments. - Residents feel dietary are not reading the diet slips. During an interview on 11/20/24 at 11:29 A.M., the Ombudsman said she was aware of concerns with the food service department including diets not being followed and concerns with the quality of food. During an interview on 11/21/24 at 8:18 A.M., the [NAME] said that diet aides are responsible for putting the condiments on the Resident's trays. During an interview on 11/21/24 at 9:12 A.M., the Dietitian said she was aware of the Residents condiment concerns as an on-going issue. The Dietician said she is responsible to review any menu substitutions before they are made. During an interview on 11/21/24 at 10:09 A.M., the Food Service Director said condiments should be on the Residents trays and menu changes should be posted. During an interview on 11/21/24 at 9:32 A.M., the Director of Nursing said he conducted the Resident Council meeting on 10/23/24, in the absence of the Activities Director. The DON said that he was aware of the Residents' on-going food concerns. During an interview on 11/21/24 at 9:53 A.M., Administrator #2 said that she attended the Resident Council meeting on 9/12/24. Administrator #2 said there should be condiments available on the Residents' trays and there should be condiments on the units. During an interview on 11/21/24 at 9:47 A.M., Administrator #1 said a grievance should be filed on behalf of the Residents regarding the on-going food service concerns brought forward during Resident Council.

Based on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on two of three nursing units. Findings include: Review of the facility policy titled Confidentiality of Information and Personal Privacy, dated February 2022, indicated the facility will protect and safeguard resident confidentiality and personal privacy. On 11/19/24 at 6:58 A.M., the surveyor observed the computer screen on a medication cart on the first floor. There was no nurse in the area and the computer screen was open displaying various residents' names, photos and identifying information. On 11/19/24 at 8:32 A.M., the surveyor observed the computer screen on a medication cart on the second floor. There was no nurse in the area and the computer screen was open displaying various residents' names, photos and identifying information. On 11/20/24 at 7:06 A.M., the surveyor observed the computer screen on a medication cart on the first floor. There was no nurse in the area and the computer screen was open displaying various residents' names, photos and identifying information. On 11/20/24 from 11:29 A.M. to 11:35 A.M., the surveyor observed the computer screen on a medication cart on the first floor. There was no nurse in the area and the computer screen was open displaying various residents' names, photos and identifying information. During an interview and observation on 11/20/24 at 11:35 A.M., Unit Manager #1 said the medication administration computer screen should never be left open to a resident screen unless the nurse is present at the medication cart. Unit Manager #1 said there was no nurse currently at the cart and the resident screen was open. During an interview on 11/21/24 at 8:20 A.M., the Director of Nursing (DON) said that resident information should not be visible to anyone other than the nurse attending the medication cart.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for 5 Residents (#55, #87, #4, #252, #13) out of a total of 24 sampled residents. Specifically, 1. For Resident #55, the facility failed to implement a physician's order to offload heels and to apply waffle boots. 2. For Resident #87, the facility failed to obtain weights as ordered. 3. For Resident #4, the facility failed to ensure nursing implemented a physician's order for weights and failed to document those weights in the electronic health record. 4. For Resident #252, the facility failed to ensure physicians orders were implemented for the monitoring of a peripheral intravenous (IV) site. 5. For Resident 13, the facility failed to obtain physician orders for the care of a central line. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, 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 the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. 1. Resident #55 was admitted to the facility in September 2024 with diagnoses that included severe protein-calorie malnutrition, dysphagia, cerebral palsy, and epilepsy. Review of Resident #55's most recent Minimum Data Set (MDS) assessment, dated 10/30/24, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated the Resident is dependent on staff for activities of daily living (ADLs) and dependent on staff for positioning. Further review of the MDS indicated he/she was at risk for developing pressure ulcers. Review of Resident #55's Norton Score (a tool to assess the risk of developing pressure ulcers), dated 10/23/24, indicated a score of 9 indicating the Resident is at very high risk for developing pressure ulcers. Review of Resident #55's physician orders, dated 10/23/24, indicated Heels off bed surface at all times, Waffle Boots. On 11/19/24 at 8:19 A.M., 9:09 A.M., and 9:40 A.M., the surveyor observed the Resident laying in bed with his/her feet flat on the bed without wearing waffle boots. On 11/20/24 at 7:00 A.M., 7:44 A.M., 8:49 A.M.,9:38 A.M., and 9:58 A.M. and 10:23 A.M., the surveyor observed the Resident laying in bed with his/her feet flat on the bed and without wearing waffle boots. During an interview and observation on 11/20/24 at 10:32 A.M., Unit Manager #1 said Resident #55's heels are not off loaded and he/she does not have waffle boots on as ordered. Unit Manager #1 said the Resident is at risk for skin breakdown. 2. Resident #87 was admitted to the facility in October 2024 with diagnoses that included adult failure to thrive, chronic diastolic congestive heart failure (CHF), and spinal stenosis. Review of Resident #87's most recent Minimum Data Set (MDS) assessment, dated 11/3/24, indicated he/she scored a 15 out 15 on the Brief Interview for Mental Status (BIMS) exam indicating the Resident is cognitively intact. Review of Resident #87's nutritional assessment, dated 11/1/24, indicated He/she continues to be at risk for weight fluctuations r/t (related to) fluid shifts and CHF. Recommendations: Monitor wts (weights), labs, intake. Review of Resident #87's nutritional care plan, dated 11/3/24, indicated Weights as ordered. Review of Resident #87's Nurse Practitioner (NP) progress note, dated 11/12/24, indicated Cont (continue) with daily weigths [sic] Hypertension. Review of Resident #87's physician order, dated 11/14/24, indicated Daily weight in the morning for Hypertension. Review of Resident #87's Certified Nurse Aide (CNA) Kardex (form explaining the needs of a resident), dated 11/20/24, indicated weigh weekly and weigh PRN (as needed). Review of Resident #87's weights indicated the last weight obtained was on 11/11/24. During an interview on 11/20/24 at 10:24 A.M., Certified Nurse Aide (CNA) #1 said the nurses tell them who needs to be weighed and then they tell the nurse what the weight is. CNA #1 said the daily weights are done at 6:00 A.M. and the night shift staff will weigh those residents. During an interview on 11/20/24 at 10:26 A.M., Nurse #1 said after the Resident is weighed it should be documented in the medical record in the vitals section. During an interview and medical record review on 11/20/24 at 10:30 A.M., Unit Manager #1 reviewed Resident #87's weights with the surveyor and said the last weight that was recorded was on 11/11/24. Unit Manager #1 said staff are supposed to obtain the Resident's weight daily, as ordered. 44095 3. Resident #4 was admitted to the facility in August 2021 with diagnoses including diabetes, atrial fibrillation, heart failure, and pain. Review of the Minimum Data Set (MDS) assessment, dated 11/1/24, indicated Resident #4 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15 which indicated he/she was cognitively intact. Review of Resident #4's plan of care related to cardiac disease and congestive heart failure, dated 8/4/21, indicated: - Obtain weights as indicated and report significant changes, dated as revised 2/23/23. Review of Resident #4's plan of care related to nutritional status, dated 8/26/24, indicated: - Weights as ordered. Review of Resident #4's physician's order, dated 7/31/23, indicated: - Weight twice a week, in the morning every Monday, Friday related to type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #4's vital signs on 11/21/24, indicated his/her most recent weight was recorded on 10/17/24 at 8:18 A.M., as 289 pounds. Review of Resident #4's Medication Administration Record (MAR), dated September 2024, October 2024, and November 2024, indicated that nursing implemented the physician's order for twice weekly weights. The MAR indicated nursing staff weighed Resident #4 on the following dates: 9/2/24, 9/6/24, 9/9/24, 9/13/24, 9/16/24, 9/20/24, 9/23/24, 9/27/24, 9/30/24, 10/4/24, 10/7/24, 10/11/24, 10/14/24, 10/18/24, 10/21/24, 10/24/24, 10/28/24, 11/1/24, 11/4/24, 11/8/24, 11/11/24, 11/15/24, and 11/18/24. Further review of the MAR failed to indicate nursing staff documented the obtained weights and there were no weights documented under the weights tab in the electronic health record. During an interview on 11/20/24 at 9:41 A.M., Nurse #3 said that Resident #4 does not have twice weekly weights. Nurse #3 said that if t weights are due the order will show up on the MAR and she will ask the nursing assistants to obtain the weights. Nurse #3 said the nursing assistants inform her of the weights and she then enters these values under the weights and vitals tab. During an interview on 11/21/24 at 6:41 A.M., Resident #4 said he/she has not been weighed in about a month. During a follow-up interview on 11/21/24 at 6:43 A.M., Nurse #3 said that Resident #4 hasn't been weighed in over a month and Nurse #3 doesn't obtain Resident #4's weights in the morning. The surveyor and Nurse #3 reviewed Resident #4's electronic health record and she said that Resident #4's last weight was like a month ago on 10/17/24 and she said Resident #4 is ordered for monthly weights. During an interview on 11/21/24 at 9:15 A.M., the Director of Nursing said nursing staff are required to implement the physician's orders for weights and enter the values in the clinical record. 36876 4. Review of the Peripheral and Midline IV Dressing Changes policy dated March 2022 indicated: the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections associated with contaminated, loosened, or soiled catheter site dressings. Assess the peripheral/midline access device at least every four hours. Resident #252 was admitted to the facility in November 2024 with diagnoses including urinary tract infection, generalized edema, and depression. There was no Minimum Data Set assessment available for Resident #252. Review of the hospital discharge paperwork dated 11/16/24 indicated Resident #252 was admitted to the facility with a peripheral IV in his/her right arm: Active Lines/Drains: Peripheral IV Right; anterior forearm Placement date: 11/24/23 Size (Gauge): 22 G (indicating the size of the needle) Catheter Length 1.75 inch Line Status: Capped Line Care: Flushed; connections checked and tightened Dressing Type: TSM (transparent Dressing Status: Clean, dry, intact Review of the admission nursing assessment dated [DATE] indicated: Infusions/access sites: Type of device - Peripheral. Site: IV line. Review of the physicians' orders and care plans failed to indicate any orders were initiated or implemented regarding the monitoring or care of Resident #252's IV site. During an interview on 11/21/24 at 7:26 A.M., Unit Manager #1 said that when residents are admitted to the facility with an IV site, the expectation is for physician orders to be initiated and implemented regarding dressing changes, flushes and monitoring the IV site. During an interview on 11/21/24 at 8:20 A.M., The Director of Nursing said that when residents are admitted with an IV site, the expectation would be for physician orders to be initiated upon admission for monitoring and flushing. 36797 5. Resident #13 was admitted to the facility in July 2024 with diagnoses including lung cancer, schizoaffective disorder, and bipolar disorder. On 11/19/24, at 9:10 A.M., the surveyor observed Resident #13 lying in bed with a central line in the upper left chest wall covered by a transparent dressing. The surveyor observed that there was no date on the dressing indicating when the dressing was applied. During an interview on 11/19/24, at 9:10 A.M., Resident #13 said that the central line was placed for Chemotherapy a few days ago. Review of the progress note dated 11/15/24 indicated that Resident #13 had an appointment for Port (central line) placement. Review of the medical record failed to indicate a doctor's order for the care of a central line. Review of the care plan failed to indicate a plan of care for the central line. During an interview on 11/20/24 at 1:02 P.M. the Director of Nursing said that all central lines require a plan of care and doctor's orders for their maintenance.

Based on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of three nurses observed made seven errors out of 30 opportunities, resulting in a medication error rate of 23.33%. Those errors impacted three Residents (#15, 22 and #48), out of three residents observed. Findings include: Review of the facility policy titled Administering Oral Medications dated revised October 2010 indicated that; #6: Check the label on the medication and confirm the medication name and dose with the MAR (medication administration record). #8 Check the medication dose. Re-check to confirm the proper dose. 1. Resident #15 was admitted to the facility in July 2022 with diagnoses including cancer, muscle weakness and anxiety disorder. On 11/20/24 at 8:48 A.M., the surveyor observed Nurse #6 give Resident # 15 the following medications: Omeprazole 20 mg (milligrams) 1 tablet Amlodipine 5 mg 2 tablets Refresh eye drops 1 drop each eye. Fluticasone nasal spray one spray each nostril Dairy aid 1 tablet Metoprolol tartrate 25 mg 1 tablet Sertraline 100 mg (3) 1/2 tablets to = 150 mg Review of the doctor's orders indicated to give: Omeprazole 20 mg (milligrams) 1 tablet Amlodipine 5 mg 2 tablets Refresh eye drops 1 drop each eye. Fluticasone nasal spray one spray each nostril Dairy aid 1 tablet Metoprolol tartrate 25 mg 1 tablet Sertraline 100 mg (3) 1/2 tablets to = 150 mg Aspirin enteric coated tablet delayed release 81 mg (not given) Magnesium Oxide 400 mg give 2 tablets two time a day (not given) 2. Resident #22 was admitted to the facility in August 2020 with diagnoses including heart disease and stroke. On 11/20/24, at 9:48 A.M., the surveyor observed Nurse #4 give Resident #22 the following medications: Sulfasalizine 500 mg 1 tablet Clopidogrel 75 mg 1 tablet Lasix 20 mg 1 tablet Duloxetine 60 mg 1 tablet Gabapentin 300 mg 2 tablets Lisinopril 5 mg 1 tablet Hydroxychloroquine 200 mg 1 tablet Senna 8.6 mg 1 tablet Ferrous Gluconate 324 mg 1 tablet Folic acid 400 mg 2 tablets Vit D3 2000 iu (international units) Acetaminophen 325 mg 2 tablets Review of the doctor's orders indicated to give: Sulfasalizine 500 mg 1 tablet Clopidogrel 75 mg 1 tablet Lasix 20 mg 1 tablet Duloxetine 60 mg 1 tablet Gabapentin 300 mg 2 tablets Lisinopril 5 mg 1 tablet Hydroxychloroquine 200 mg 1 tablet Senna 8.6 mg 2 tablets (gave 1 tablet) Ferrous Gluconate 239 mg 1 tablet (gave 324 mg) Folic acid 1000 mg 1 tablets (gave 800 mg) Vit D3 2000 iu (international units) Acetaminophen 325 mg 2 tablets Famotidine 20 mg 1 tablet (not given) 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including osteomyelitis, opioid dependence and liver failure. On 11/20/24 at 8:09 A.M., the surveyor observed Nurse #7 give Resident #48 the following medications: Gabapentin 400 mg 2 tablets Meformin 1000 mg 1 tablet Acetaminophen 325 mg 2 tablets folic acid 1000 mg 1 tablet Lasix 40 mg 1 tablet Jardiance 25 mg 1 tablet Lidocaine 4% patch Losartan Pot. 100 mg 1 tablet multivitamin with iron 1 tablet Vit B1 100 mg 1 tablet Ceftriaxone 2 gm (grams) NS (normal saline) 100 ml (milliliters) IV Review of the doctor's orders indicated to give: Gabapentin 400 mg 2 tablets Meformin 1000 mg 1 tablet Acetaminophen 325 mg 3 tablets (gave 2 tablets) folic acid 1000 mg 1 tablet Lasix 40 mg 1 tablet Jardiance 25 mg 1 tablet Lidocaine 4% patch Losartan Pot. 100 mg 1 tablet multivitamin with iron 1 tablet Vit B1 100 mg 1 tablet Ceftriaxone 2 gm (grams) NS (normal saline) 100 ml (milliliters) IV During an interview on 11/20/24 at 1:02 P.M., the Director of Nursing (DON) said that the medication error rate was above acceptable limits. The DON said that all medications are to be given as ordered by the physician.

Based on observation and interview, the facility failed to ensure medications were properly secured. Specifically: 1. The facility failed to ensure medications were not left unattended on medication carts, at nurses' stations and in resident rooms. 2. The facility failed to ensure a medication cart was locked when unattended on the 3rd floor. 3. The facility failed to ensure medications were not left unattended at the bedside for Resident #4. 4. The failed to ensure medications were labeled with date opened. 5. The failed to ensure medications were not left unattended on top if the medication cart. 6. For Resident #201, the facility failed to ensure medication was not stored at bedside. Findings include: Review of the facility's Medication Labeling and Storage policy, dated February 2023, indicated: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and tray carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. On 11/19/24 at 1:21 P.M., the surveyor observed two medication cards on top of an unlocked medication cart on the 1st floor. One medication card contained one 100 milligram (mg) tablet of gabapentin (a medication used to treat pain), and one card containing eleven 60 MG tablets of Duloxetine (a medication used to treat anxiety and depression). Nurse #2 exited a resident room and approached the cart. Nurse #2 said that the medications should not have been left on top of the cart unattended. On 11/21/24 at 6:51 A.M., the surveyor observed four medication cards unattended on the desk of the first floor nurses station. The medication cards contained twenty-five 50 mg tablets of Hyoscyamine (medication used to treat stomach and intestinal disorders), twenty-one 50 mg tablets of Losartan (medication used to treat blood pressure) and twenty-one tablets of 50 mg Famotidine (a medication used to reduce stomach acid). Unit Manager #1 then arrived to the unit and removed the medication cards. On 11/21/24 at 9:43 A.M., the surveyor observed three medication cups on a resident's bedside table. Licensed nursing staff were not in the bedroom. The cups were behind the resident's back, and he/she could not observe them. One medication cup had one small white pill inside, one medication cup had approximately 6 tablets inside, and one medication cup was filled with an amber-like fluid. The medication cups contained the following medications: one capsule Gabapentin 300 mg (used to treat pain), one tablet Torsemide 20 mg (used to treat kidney disease), one darolutamide tablet 300 mg (used to treat prostate cancer), one multi-vitamin tablet, one tablet Pantoprazole Sodium Tablet 40 mg (used to treat acid reflux), one Ferrous Sulfate Tablet 325 mg (used to treat low iron levels), one Finasteride Tablet 5 mg (used to treat prostate cancer), one Amlodipine Tablet 10 mg (used to treat hypertension). During an interview on 11/21/24 at 7:26 A.M., Unit Manager #1 said medications should not be left unattended. 44095 2. The facility failed to ensure a medication cart was locked when unattended on the 3rd floor. On 11/21/24 at 6:46 A.M., the surveyor observed the 3rd floor East medication cart unlocked and unattended. There were two housekeeping employees, two therapy employees, one resident, and the dietitian within the vicinity of the unlocked and unattended medication cart. On 11/21/24 at 6:51 A.M., the surveyor observed Nurse #3 return to the unlocked and unattended medication cart. During an interview on 11/21/24 at 9:25 A.M., the Director of Nursing (DON) said medication carts should be locked when unattended. 3. The facility failed to ensure medications were not left unattended at the bedside for Resident #4. On 11/19/24 at 10:52 A.M., 11/20/24 at 6:39 A.M., 11/20/24 at 8:47 A.M., 11/20/24 at 12:50 P.M., 11/20/24 at 4:11 P.M., 11/21/24 at 6:41 A.M., and on 11/21/24 at 10:22 A.M., the surveyor observed two lidocaine 5% patches on Resident #4's bedside table sitting directly on top of a plastic organizer. On 11/21/24 at 10:22 A.M., the surveyor, accompanied by Nurse #5, went to Resident #4's bedroom. Nurse #4 said that the lidocaine patches should not be left unattended at the bedside. During an interview on 11/21/24 at 9:17 A.M., the DON said the lidocaine patches should be stored in the medication cart and not at Resident #4's bedside. 36797 4. On 11/21/24 at 8:24 A.M. the surveyor observed a Wixela inhaler (used to treat asthma) open without a date inside the [NAME] unit medication cart. Review of the manufacturer's directions indicated to discard the inhaler one month after opening. Review of the inhaler's pharmacy label indicated that the inhaler was received by the facility on 9/25/24. During an interview on 11/21/24 at 8:24 A.M., Nurse #6 said that the inhaler should have been dated when opened. On 11/21/24 at 8:26 A.M., the surveyor observed a bottle of Tuberculin derivative (used to test for tuberculosis) open and without an opened date. During an interview on 11/21/24 at 8:30 A.M., Nurse #6 said that the bottle of Tuberculin derivative should have been dated when opened. Nurse #6 then said that any accessed bottle of injectable medication is only good for 1 month. 5. On 11/20/24, at 9:50 A.M., the surveyor observed Nurse #4 leave 2 cards of medications on top of the medication cart in the hallway and enter a resident's room, out of sight of the medication cart. During an interview on 11/20/24, at 9:55 A.M., Nurse #4 said that she should not have left the medication on top of the medication cart, unattended. 6. Resident #201 was admitted to the facility in November 2024 with diagnoses including osteomyelitis (infection of the bone), spinal abscess with drains in the back and intravenous antibiotic use. On 11/19/24 at 8:08 A.M., and at 12:30 P.M., the surveyor observed a bottle of Motrin B on Resident #201's over the bed table. Review of the medical record failed to indicate Resident #201 was assessed for self-administration of medication. During an interview on 11/20/24 11:15 A.M., Resident #201 said that he/she put the bottle of Motrin in his/her backpack. During an interview on 11/20/24 11:20 A.M., Nurse #4 said that Resident #201 is not supposed to have medications at bedside.

Based on record review and interview, the facility failed to accurately document in the clinical records for 4 residents (#30, #67, #77 and #1) of 24 sampled residents. Specifically: 1. For Resident #30, the facility failed to document diabetic foot care. 2. For Resident #67, the facility inaccurately documented O2 (oxygen) tubing changed when it was not. 3. For Resident #77, the facility inaccurately documented a hand splint/brace was on when it was not. 4. For Resident #1, the facility failed to ensure staff documented the administration of medications. Review of the Documentation of Medication Administration policy dated November 2022 indicated: A medication administration record is used to document all medications administered. Documentation of medication administration includes . date and time of administration, reason(s) why a medication was withheld, not administered, or refused (as applicable); initials, signature and title of the person administering the medication. Review of the facility policy titled Charting and Documentation, dated revised July 2017 indicated that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Resident #30 was admitted to the facility in February 2024, and has active diagnoses which include diabetes mellitus and dementia. Resident #30 had no documented incidents of refusing care. Review of Resident #30's physician orders dated 2/15/24 indicated Diabetic foot care every evening shift. Review of Resident #30's Treatment Administration Record (TAR) dated November 2024 indicated staff did not document if diabetic foot care was provided on 11/6/24, 11/8/24, 11/10/24, 11/12/24 and 11/14/24. During an interview with the Director of Nursing (DON) on 11/21/24 at approximately 9:10 A.M., he said licensed nursing staff are required to document whether a physician's order was completed, or not, in the Treatment Administration Record. The DON said diabetic foot care was not documented as complete for Resident #30 on 11/6/24, 11/8/24, 11/10/24, 11/12/24 and 11/14/24. 36797 2. Resident #67 was admitted to the facility in October 2021 with diagnoses including chronic obstructive pulmonary disease, heart disease, and kidney disease. On 11/19/24 at 8:38 A.M., the surveyor observed Resident #67 lying in bed receiving oxygen via nasal cannula, attached to an oxygen concentrator. The surveyor observed the oxygen tubing to be dated 10/11/24. Review of the doctor's orders indicated an order dated 10/26/22 to change nasal cannula weekly. Further review indicated an order dated 10/11/21 to change all disposable oxygen supplies every week and as needed. Label and date all supplies. Review of the Medication Administration Record (MAR) dated November 2024 inaccurately indicated that the O2 tubing was changed 11/6/24 and 11/13/24. During an interview on 11/20/24 at 10:45 A.M., Unit Manager #2 said that all oxygen tubing was supposed to be changed weekly. During an interview on 11/20/24, at 1:02 P.M., the Director of Nursing (DON) said that nursing should not have documented the O2 tubing was changed when it wasn't. 3. Resident #77 was admitted to the facility in June 2023 with diagnoses including stroke with left sided hemiplegia/hemiparesis, diabetes and depression. Review of the Minimum Data Set assessment dated [DATE], indicated a score of 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Further review indicated that Resident #77 is totally dependent for activities of daily living (ADLs) and has impairments to his/her upper and lower body. Review of the doctor's order dated 10/26/23, indicated an order for left hand splint on in the morning, off in the evening as tolerated. Review of the care plan dated as initiated 6/28/23 indicated a focus of self care deficit with interventions including left hand splint on during the day as tolerated and off in the evening. On 11/19/24 at 8:30 A.M., the surveyor observed Resident #77 in his/her room without a hand brace on the left hand. The surveyor further observed that there was no hand brace in Resident #77's room. During an interview on 11/19/24 at 8:30 A.M., Resident #77 said that he/she has a hand brace for the left hand but it has been missing for about a month. Resident #77 said that the hand brace was sent down to laundry and never came back. On 11/19/24 at 1:06 P.M., the surveyor observed Resident #77 in the 2nd floor dining room without a hand brace on. Review of the Medication Administration Record (MAR) dated November 2024 indicted that Resident #77 was wearing a splint on the left hand 33 out of 33 possible shifts. During an interview on 11/20/24 at 10:39 A.M., Resident #77 was observed to have a blue brace on the left hand but Resident #77 said it was the wrong brace and he/she didn't know where it came from. During an interview on 11/20/24 at 10:39 A.M., Certified Nurse's Aide (CNA) #4 said that it was the responsibility of the CNA to apply any braces. During an interview on 11/20/24 at 10:45 A.M., Unit Manager #2 said that she was not aware that Resident #77 is wearing the wrong brace. During an interview on 11/20/24 10:49 A.M. Physical Therapist (PT) #1 said that Resident #77 is not wearing the correct brace on his/her left hand. She then said that the facility has ordered the correct brace. PT #1 then said that the brace had been ordered on 10/24/24 and received on 10/31/24 but had been given to another resident who went home. PT #1 then said that she dropped the ball and forgot to order Resident #77 another brace. During an interview on 11/20/24 at 1:02 P.M., the Director of Nursing (DON) said it is the nurse's responsibility to ensure braces have been applied to the residents and to document in the medical record accurately. 36876 4. Resident #1 was admitted to the facility in February 2024 with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 is severely cognitively impaired as evidenced by a score of one out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). Review of the November 2024 Medication Administration Record (MAR) on 11/19/24 indicated the following: Atorvastatin Calcium tablet 80 MG, give via G tube in the evening: nursing did not sign off the medication was administered on 11/5/24, 11/8/24 and 11/18/24. Polyethylene Glycol 3350 Powder; give 17 gram once a day: nursing did not sign off the medication was administered on 11/16/24. Quetiapine Fumarate Oral Tablet 25 MG give 1 tablet at bedtime: nursing did not sign off the medication was administered on 11/5/24, 11/7/24 and 11/9/24. Amlodipine Besylate 5 MG give two times a day; nursing did not sign off the medication was administered during the morning shift on 11/16/24. Acetaminophen Tablet 500 MG give two caplet every 8 hours for pain: Nursing did not sign off the dosages were administered the evening shifts of 11/5/24, 11/8/24, 11/10/24, 11/14/24 and 11/18/24. Enteral Feed every shift Glucerna 1.5 full strength continuously rate: 45 ml/hr: nursing did not sign off the feed was administered on the morning shift on 11/16/24 and evening shifts on 11/5/24, 11/8/24, 11/10/24 and 11/18/24. Artificial Tears Solution 1.4%, instill 2 drops in both eyes every 6 hours: nursing did not sign off that the drops were administered on the evening shifts on 11/5/24, 11/8/24, 11/16/24, and 11/18/24. Guaifenesin give 10ML every 6 hours: nursing did not sign off the medication as being administered on the evening shifts on 11/5/24, 11/8/24, 11/16/24 and 11/18/24. Insulin 100 unit/ml, inject 8 units subcutaneously every 6 hours: nursing did not sign off the medication as being administered on the afternoon shift on 11/16/24 and the evening shifts on 11/5/24, 11/7/24 and 11/18/24. Metoclopramide HCL table 5 MG, give 1 tablet four times a day: nursing did not sign off the medication was administered on 11/5/24, 11/8/24, 11/16/24 and 11/18/24. Oxycodone HCL 5MG/ML, give 2.5 ml every six hours: nursing did not sign off the medication was administered on the evening shifts on 11/5/24, 11/8/24, 11/16/24 and 11/18/24. During an interview on 11/21/24 at 8:20 A.M , the Director of Nursing (DON) said that nurses are expected to document the administration or refusals of medications on the MAR.

Based on observation, record review and interview, the facility failed to ensure that one Resident (#201) did not self-administer medications out of a total sample of 24 residents. Specifically, Resident #201 was not assessed to be able to safely self-administer medication. Findings include: Review of the facility policy titled, Self Administration of Medications, dated as reviewed February 2021, indicated that as part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate. Resident #201 was admitted to the facility in November 2024 with diagnoses including post-traumatic stress disorder, anxiety disorder and depression. On 11/19/24 at 8:08 A.M., and 12:30 P.M. the surveyor observed a bottle of Motrin B on Resident #201's over the bed table. During an interview on 11/20/24 11:15 A.M., Resident #201 said that he/she put the bottle of Motrin in his/her backpack. Review of the medical record failed to indicate Resident #201 was assessed for the ability to self-administer medication. Review of the medical record failed to indicate Resident #201 was assessed for self-administration of medication. Review of the doctor's orders failed to indicate an order for Resident #201 to self-administer medication. Review of the care plan failed to indicate Resident #4 had a care plan for the self-administration of medication. During an interview on 11/20/24 at 11:20 A.M., Nurse #7 said that Resident #201 is not supposed to have medications at bedside.

Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan for one Resident (#201) out of a total sample of 24 residents. Specifically, the facility failed to develop a care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care. Findings include: Review of the facility policy titled Care Plans - Baseline, dated revised March 2022 indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. Resident #201 was admitted to the facility in November 2024 with diagnoses including osteomyelitis (infection of the bone), spinal abscess with drains in the back and intravenous antibiotic use. Review of the medical record failed to indicate a baseline care plan was developed within 48 hours of admission to the facility. Further review indicated that as of 5 days post admission, a baseline plan of care had not been developed. During an interview on 11/20/24 at 1:02 P.M., the Director of Nursing said that nursing staff should have developed a baseline care plan for Resident #201 within 48 hours of admission to the facility.

Based on observations, record review and interview the facility failed to implement resident-centered care plans for one Resident (#77) out of a total sample of 24 residents. Specifically, for Resident #77 the facility failed to implement the use of a hand brace and failed to assist with trimming fingernails. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016 indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #77 was admitted to the facility in June 2023 with diagnoses including stroke with left sided hemiplegia/hemiparesis, diabetes and depression. Review of the Minimum Data Set assessment dated [DATE], indicated a score of 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Further review indicated that Resident #77 is totally dependent for activities of daily living (ADLs)and has impairments to his/her upper and lower body. Review of the doctor's order dated 10/26/23, indicated an order for left hand splint on in the morning, off in the evening as tolerated. Review of the care plan dated as initiated 6/28/23 indicated a focus of self care deficit with interventions including left hand splint on during the day as tolerated off in the evening. Further review indicated Resident #77 is totally dependent for ADLs and to keep nails trimmed to prevent injury. On 11/19/24, at 8:30 A.M., the surveyor observed Resident #77 in his/her room without a hand brace on the left hand and fingernails that were long and jagged. The surveyor further observed that there was no hand brace in Resident #77's room. During an interview on 11/19/24 at 8:30 A.M., Resident #77 said that he/she has a hand brace for the left hand but it has been missing for about a month. Resident #77 said that the hand brace was sent down to laundry and never came back. Resident #77 then said that he/she needs help cutting his/her fingernails and staff have not helped. On 11/19/24 at 1:06 P.M., the surveyor observed Resident #77 in the 2nd floor dining room without a hand brace on and fingernails that were long and jagged. During an interview on 11/20/24 at 10:39 A.M., Resident #77 was observed to have a blue brace on the left hand but Resident #77 said it was the wrong brace. During an interview on 11/20/24 at 10:39 A.M., Certified Nurse's Aide (CNA) #4 said that it was the responsibility of the CNA to cut fingernails and to apply any braces. During an interview on 11/20/24 10:45 A.M., Unit Manager #2 said that she was not aware that Resident #77 had long nails or that he/she is wearing the wrong brace. During an interview on 11/20/24 10:49 A.M. Physical Therapist (PT) #1 said that Resident #77 is not wearing the correct brace on his/her left hand. She then said that the facility has ordered the correct brace. PT #1 then said that the brace had been ordered on 10/24/24 and received on 10/31/24 but had been given to another resident who went home. PT #1 then said that she dropped the ball and forgot to order Resident #77 another brace. During an interview on 11/20/24 at 11:05 A.M., Unit Manager #2 said that it is the facility protocol for the podiatrist to cut fingernails on residents diagnosed with diabetes. During an interview on 11/20/24 at 11:06 A.M., Unit Secretary #1 said that facility staff had never offered Resident #77 a consent to be seen by a podiatrist. During an interview on 11/20/24 at 1:02 P.M., the Director of Nursing (DON) said the podiatrist does not cut fingernails. The DON then said that CNAs are responsible for cutting fingernails and it is the nurse's responsibility to ensure braces have been applied to the residents requiring them.

Based on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one Resident (#14) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated as revised December 2016 indicated the Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. Resident #14 was admitted to the facility in July 2024 with diagnoses including schizophrenia, anxiety disorder and depression. Review of Resident #14's clinical record indicated an MDS was completed on 10/22/24. Review of Resident #4's most recent care plan indicated a target date of 10/16/24. Further review indicated the care plan was not reviewed and had not been reviewed since 7/30/24, and target dates for all goals had not been updated . During an interview on 11/20/24 at 8:14 A.M., the Director of Nursing said that care plans are to be reviewed each time the MDS is completed and new target dates should be set for all the goals.

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 3 dependent Residents (#14, #77 and #15) out of a total sample of 24 Residents. Specifically, the facility failed to: 1. For Resident #14, cut fingernails and remove unwanted chin hair. 2. For Resident #77, cut fingernails. 3. For Resident #15, remove unwanted chin hair. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting and dated revised March 2018 indicated that residents that are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Resident #14 was admitted to the facility in July 2024 with diagnoses including schizophrenia, anxiety disorder and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 scored an 8 out of 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Further review indicated that Resident #14 requires substantial assistance with bathing and dressing and requires set up assistance with personal hygiene. On 11/19/24 at 8:54 A.M., the surveyor observed Resident #14 laying in bed. The surveyor also observed Resident #14 to have long, jagged fingernails and inch-long chin hair. During an interview on 11/19/24 at 8:54 A.M., Resident #14 said that he/she is embarrassed by the hairy chin and wants his/her long nails cut. Resident #14 said that he/she is not capable of cutting his/her fingernails or removing unwanted chin hair without staff's help. On 11/20/24 at 10:56 A.M., the surveyor observed Resident #14 sitting in the [NAME] unit dining room. The surveyor also observed Resident #14 to have long, jagged fingernails and inch long chin hair. On 11/21/24 at 8:30 A.M., the surveyor observed Resident #14 with long chin hair. Review of the care plan indicated that Resident #14 requires assistance with daily hygiene, as needed. Further review failed to indicate that Resident #14 refuses care. During an interview on 11/21/24 at 8:30 A.M., Certified Nurse's Aide (CNA) #5 said that it was the responsibility of the CNAs to remove unwanted chin hair and to cut fingernails. 2. Resident #77 was admitted to the facility in June 2023 with diagnoses including stroke with left sided hemiplegia/hemiparesis, diabetes, and depression. Review of the Minimum Data Set assessment dated [DATE], indicated a score of 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Further review indicated that Resident #77 is totally dependent for activities of daily living (ADLs) and has impairments to his/her upper and lower body. Review of the care plan dated as initiated 6/28/23 indicated a focus of self-care deficit, including Resident #77 is totally dependent on staff for ADL care. Interventions included keep nails trimmed to prevent injury. On 11/19/24, at 8:30 A.M., the surveyor observed Resident #77 in his/her room with fingernails that were long and jagged. During an interview on 11/19/24 at 8:30 A.M., Resident #77 said that he/she needs help cutting his/her fingernails and staff have not helped. On 11/19/24 at 1:06 P.M., the surveyor observed Resident #77 in the 2nd floor dining room with fingernails that were long and jagged. During an interview on 11/20/24 at 10:39 A.M., CNA #4 said that it was the responsibility of the CNAs to cut fingernails. During an interview on 11/20/24 at 10:45 A.M., Unit Manager #2 said that she was not aware Resident #77 had long nails. During an interview on 11/20/24 at 11:05 A.M., Unit Manager #2 said that it is the facility protocol for the podiatrist to cut fingernails on residents diagnosed with diabetes. During an interview on 11/20/24 at 11:06 A.M., Unit Secretary #1 said that facility staff had never offered Resident #77 a consent to be seen by a podiatrist. During an interview on 11/20/24 at 1:02 P.M., the Director of Nursing (DON) said the podiatrist does not cut fingernails. The DON then said that CNAs are responsible for cutting fingernails and removing unwanted chin hair. 3. Resident #15 was admitted to the facility in July 2022 with diagnoses including cancer, muscle weakness and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15 is cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #15 is totally dependent on staff for all activities of daily living. On 11/19/24, at 9:10 A.M., the surveyor observed Resident #15 to have a significant amount of chin hair. Resident #15 said that he/she is embarrassed by the chin hair and wanted it removed. Resident #15 then said that he/she doesn't get the help he/she needs to remove the chin hair. On 11/20/24, at 12:30 P.M., the surveyor observed Resident #15 to have a significant amount of chin hair. On 11/21/24, at 9:25 A.M., the surveyor observed Resident #15 to have a significant amount of chin hair.

Based on observation, record review and interview, the facility failed to provide a meaningful activity program for one Resident (#44) out of a total of 24 sampled residents Findings include: Resident #44 was admitted to the facility in June 2023 with diagnoses including malignant neoplasm of frontal lobe and aphasia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #44 is severely cognitively impaired and requires assistance with bathing, dressing and transfers. During an interview on 11/19/24 at 10:20 A.M., the surveyor observed Resident #44 resting in bed. Family Member #1 said that she visits Resident #44 regularly and that Resident #44 is confused and bedbound. Family Member #1 said that she has not seen staff offer Resident #44 in room activities, turn his/her TV on or play music for him/her. Review of Resident #44's Activities Care Plan, dated 6/13/24, indicated: Focus: Resident experiences barriers to activities, especially communication and language barriers. Due to brain neoplasm, experiences cognitive loss and aphasia, Resident #44 is primarily nonverbal. Resident is alert but confused and forgetful. Goals: Resident #44 declines group activities at this time but will socialize weekly during family visits and staff visits. Interventions. Due to Chinese speaking as well as nonverbal, aphasic state, use interpreter as needed, also pay attention to Resident #44 facial expressions and body language, and any indications of discomfort in order to pick up nonverbal cues. Family members to bring in sentimental reminders of resident's life, photos, favorite music, favorite belongings in order to comfort resident. Provide resident daily room visits. On 11/19/24 at 2:00 P.M., Resident #44 was observed in bed awake and able to follow the surveyor with his/her eyes. There was a TV and radio in the room, but they were not on, and Resident #44 lay in the bed in silence. On 11/20/24 at 8:36 A.M., 9:52 A.M., 10:45 A.M., and 1:49 P.M., the surveyor observed Resident #44 awake and in bed. The privacy curtain was pulled, and he/she was not visible and could not see out into the hallway. The overhead light was off, and the room was dimly lit. Resident #44 lay in bed in silence as his/her TV and radio were not on. During an interview on 11/20/24 at 8:48 A.M., Nurse #2 said that Resident #44 is bedbound and refuses to get out of bed. During an interview on 11/20/24 at 1:47 P.M., the Activities Assistant said that Resident #44 does not get out of bed or attend activities. The Activities Assistant said in room visits are provided to residents who do not leave their rooms. Review of Resident #44's Activity Participation Record on 11/20/24 indicated he/she had received no in-room activities on 11/5/24, 11/9/24, 11/10/24, 11/12/24, 11/15/24, 11/16/24, 11/17/24, 11/18/24, 11/19/24 and 11/20/24. During an interview on 11/20/24 at 1:59 P.M., the Activities Director said that she has volunteers and staff that provide in-room visits and activities for residents who do not wish to leave their room. She said that they will encourage TV, the use of a radio and provide sensory support. The surveyor and the Activities Director reviewed Resident #44's Activity Participation Record, and the Activity Director said she was not aware that activities were not provided to Resident #44.

Based on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#67) out of a total sample of 24 Residents. Specifically, the facility failed to ensure the oxygen filter was clean and the oxygen tubing changed as ordered. Findings include: Review of the facility policy titled Oxygen Administration and dated revised October 2010 failed to indicate how often the oxygen tubing was to be replaced and how often the concentrator filter was to be cleaned. Resident #67 was admitted to the facility in October 2021 with diagnoses including chronic obstructive pulmonary disease, heart disease, and kidney disease. On 11/19/24 at 8:38 A.M., the surveyor observed Resident #67 lying in bed receiving oxygen via nasal cannula, attached to an oxygen concentrator. The surveyor observed the oxygen tubing to be dated 10/11/24. The surveyor also observed the concentrator filter to be covered with a gray fuzzy substance. Review of the doctor's orders indicated an order dated 10/26/22 to change nasal cannula weekly. Further review indicated an order dated 10/11/21 to change all disposable oxygen supplies every week and as needed. Label and date all supplies. During an interview on 11/20/24 at 10:45 A.M., Unit Manager #2 said that all oxygen tubing was supposed to be changed weekly. During an interview on 11/20/24, at 1:02 P.M. the Director of Nursing (DON) said that the concentrator air filters get cleaned according to manufacturer's instructions. The DON was not able to state what those directions were nor was he able to produce the directions to the surveyor.

Based on observation, record review, and interview the facility failed to prevent a worsening contracture for 2 Residents (#58 and #38) out of a total sample of 36 residents. Findings include: 1. Resident #58 was admitted in August, 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #58 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) examination, which indicated severe cognitive impairment. The MDS also indicated Resident #58 required extensive staff assistance to dependent care from staff with all activities of daily living. During an observation on 10/5/22 at 8:00 A.M., Resident #58 was lying in bed without a splint on his/her left hand and the left hand was in a closed position and bending to the left at the wrist. During an observation on 10/6/22 at 9:56 A.M., Resident #58 was lying in bed without a splint on his/her left hand and his/her left hand was closed and the hand was bending to the left at the wrist. Review of Resident #58's medical record indicated he/she had received occupational therapy services from September 2021 to January 2022. The occupational therapy evaluation, dated 9/21/21, indicated Resident #58 was evaluated for skilled services for a left hand/digit/wrist/shoulder contracture. Resident #58 was assessed to have a 55 degree ulnar deviation (bending of the wrist towards the pinky finger) contracture of the left wrist. Resident #58 was assessed to have 0 to 70 degrees of left shoulder flexion (ability to raise arm over head). Review of the Occupational Therapy Discharge Summary, dated 1/18/22, indicated that Resident #58 was discharged with improved ulnar deviation of the left wrist to 10 degrees of deviation. Resident #58 also demonstrated range of motion of the left shoulder to 105 degrees of flexion. Resident #58 was discharged with a splint. During an interview on 10/06/22 at 12:43 P.M., the Director of Rehabilitation (DOR) said nursing is responsible for sending a referral to the therapy department if they notice a change in function or range of motion. The DOR said Resident #58 had been treated by occupational therapy at the start of the year for left hand and left shoulder contractures and had been given a hand splint when discharged from treatment. The DOR said nursing had been educated regarding how to put on Resident #58's splint as well as the splint wearing schedule. The DOR said nursing is responsible for monitoring the splint use and if there is a change in a resident's ability to use the splint. The DOR said she had not received a recent referral for Resident #58 and was unaware he/she had not been wearing his/her left hand splint. The DOR said occupational therapy was going to evaluate Resident #58 to assess whether there had been a decline in his/her range of motion since discharge from occupational therapy in January 2022. Resident #58 was evaluated by the Occupational Therapist on 10/6/22. Resident #58's range of motion in his/her left shoulder flexion was documented to be 90 degrees, a 15 degree worsening from the previous discharge summary. Resident #58's ulnar deviation range of motion was documented to be 30 degrees, a 20 degree worsening of range of motion from the previous discharge summary. During a follow-up interview on 10/11/22 at 12:51 P.M., the DOR said Resident #58 was evaluated by occupational therapy to assess for possible worsening contracture. The DOR said Resident #58 had increased ulnar deviation of the left wrist and decreased flexion of the left shoulder. 2. For Resident #58, the facility failed to prevent a knee contracture. Resident #38 was admitted in January /2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/29/22, indicated that Resident #38 scored a 0 on the Brief Interview for Mental Status (BIMS) examination, indicating an inability to participate. Review of the MDS indicated that Resident #38 requires extensive staff assistance for all activities of daily living, was totally dependent with bathing, and needed supervision at meals. During an observation on 10/11/22 at 8:00 1:15 P.M., Resident #38 was lying in bed with his/her right knee bent in bed. Resident #38 said he/she could not extend his/her knee. Review of Resident #58's medical record indicated he/she had received occupational therapy services from February 2022 to March 2022. Review of the Physical Therapy Initial Assessment, dated 2/24/22 indicated that Resident #38 started both physical therapy and occupational therapy rehab services for a left metatarsal fracture and left tibial fracture after a fall. Review of the physical therapy treatment note, dated 3/24/22, indicated the following: - Patient is discharged from skilled therapy from med A, will re-evaluate under med B in one week. Review of the occupational therapy treatment note, dated 3/24/22, indicated the following: - Patient discharging from med A, will be re-evaluated under part B - patient still appropriate for skilled occupational therapy. During an interview on 10/11/22 at 1:25 P.M., CNA #8 said that she could not extend Resident #58's left leg fully. During an interview on 10/06/22 at 12:43 P.M., the Director of Rehab (DOR) said nursing is responsible for sending a referral to the therapy department if they notice a change in function or range of motion.

Based on observations, interviews, policy review and record reviews, the facility failed to 1) address significant weight loss for 2 Residents (#17 and #82) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, revised March 2022, indicated the following: *Residents are weighed upon admission and at intervals established by the interdisciplinary team such as weekly for four weeks, then monthly unless otherwise indicated or as ordered. *A weight change of 5 lbs (pounds) or more in a patient weighing more than 100 lbs or of 2 lbs in a patient weighing less than 100 lbs since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the Dietitian. For non-significant weight changes either the dietitian or provider is notified upon consideration of the resident's overall clinical condition. *The Dietitian will follow-up within 1 week. *The Dietitian will discuss undesired weight changes (loss or gains) with the resident and/or family. 1. Resident #17 was admitted to the facility in July 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) examination score of 15 out of a possible 15, indicating intact cognition. Review of Resident #17's weights indicated the following: *On 07/08/22 Resident #17 weighed 190 lbs. (pounds) *On 08/24/22 Resident #17 weighed 182.2 lbs. *On 08/29/22 Resident #17 weighed 182. 4 lbs. *On 09/09/22 Resident #17 weighed 172.1 lbs, a 9.42 % loss in 2 months and a 5.65% loss within the last month. Review of Resident #17's physician orders dated 7/19/22 indicated weekly weights. Review of Resident #17's weight log indicated on 4 weights were taken out of the possible 13 weeks the Resident has been in the facility, Review of Resident #17's medical record failed to indicate he/she had a cast to treat his/her leg fracture and there was no indication the Resident was experiencing [CONDITION(S)] when first admitted to the facility. During an interview on 10/12/22 at 8:49 A.M., Resident #17 said he/she was unaware he/she had lost weight and that no staff, including the Dietitian or Physician, had spoken to him/her about it. Resident #17 said he/she would have liked to speak to someone about his/her weight loss. Review of Resident #17's medical record failed to indicate Resident #17's physician was notified of the Resident's significant weight loss or that the Dietitian had assessed Resident #17 after the significant weight loss recorded on 9/9/22. The last nutritional assessment for Resident #17 was completed on 7/14/22 at the time of his/her admission to the facility. During an interview on 10/07/22 at 12:55 P.M., the Dietitian says she monitors all resident weights daily and uses the weight report and weight logs to do this. The Dietitian said a weight loss of 5% in one month and 7.5% in 3 months would indicate a significant weight loss. The Dietitian said if a significant weight loss occurs, she is expected to assess the resident within 1 week and begin new interventions to prevent further weight loss. The Dietitian said she was aware of Resident #17's significant weight loss but had not yet assessed the Resident or initiated any new interventions. She confirmed it had been 1 month since the weight loss had occurred. During an interview on 10/7/22 at 1:18 P.M., the Director of Nursing said she was unaware of Resident #17's weight loss. 2. Resident #82 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #82's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a score of 0 on the Brief Interview for Mental Status examination, indicating an inability to participate in the exam. Review of Resident #82's weight log indicated the following: *On 8/16/22, Resident #82 weighed 115.1 lbs. (pounds) *On 9/6/22 Resident #82 weighed 104 lbs. *on 9/13/22 Resident #82 weighed 106.4 lbs 7.56% weight loss in 1 month. Review of Resident #17's medical record indicated the Dietitian assessed Resident #17 on 9/7/22. During this assessment, the Dietitian recommended initiating oral supplements to optimize nutrition due to suspected weight loss. Review of Resident #17's physician orders indicated the following order written on 9/23/22, over two weeks after the Dietitian's recommendation: *Glucerna 237 ml 2x/day for weight loss, malnutrition risk. During an interview on 10/11/22 at 10:59 A.M., the Dietitian said she was aware of Resident #82's significant weight loss and had made recommendations to prevent further weight loss. The Dietitian said she was aware that the interventions she recommended were delayed and should have been implemented immediately.

Based on observation, interview, and record review the facility failed to address pain after 1 Resident (#38) verbally expressed pain in the right leg, out of a total sample of 36 residents. Findings include: Review of the facility policy titled Pain Assessment and Management, dated 5/19/20, indicated the following: - Pain management is a multidisciplinary care process that includes the following: - Assessing the potential for pain - Recognizing the presence of pain - Identifying the characteristics of pain - Addressing the underlying causes of pain - Developing and implementing approaches for pain management - Identifying and using specific strategies for different levels and sources of pain - Monitoring the effectiveness of interventions and modifying approaches as necessary Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments when there is a significant change in condition and when there is an onset of new pain or worsening of existing pain. Acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Report the following information to the physician or practitioner: - Significant changes in the level of resident's pain - Prolonged or unrelieved pain despite care plan interventions Resident #38 was admitted in January, 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 7/29/22, indicated a score of 0 on the Brief Interview for Mental Status (BIMS) examination, indicating an inability to participate. Review of the MDS indicated that Resident #38 was an extensive assist for all activities of daily living, total dependence with bathing, and supervision at meals. There was no indication in the medical record that Resident #38 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/6/22 at 11:05 A.M., Resident #38 was repeating the word pain and pointing to his/her right leg and foot. The surveyor notified Nurse #3 of the pain that Resident #38 was reporting. During an interview on 10/6/22 at 1:55 P.M., Resident #38 said that he/she was in pain and that it was not addressed by nursing. During an interview and observation on 10/6/22 at 2:00 P.M., Nurse #3 said that she came in to assess Resident #38 after the surveyor had told her of the pain and that the Resident was not in pain. The surveyor explained that Resident #38 was still in pain of the right leg. Nurse #3 went to touch Resident #38's foot and Resident #38 yelled out in pain and said no, no, no. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of refusal in the record. Review of the medical record did not indicate that a physician or nurse practitioner was notified of Resident #38's pain on 10/6/22. During an interview on 10/7/22 at 8:36 A.M., Resident #38 verbalized he/she was still in pain in the right leg and was in an 8-10 level of pain. Resident #38 said that he/she feels that staff are not managing his/her pain effectively. Resident #38 said that he/she never saw the physician or nurse practitioner and that Nurse #3 did not address his/her pain. During an interview on 10/7/22 at 11:17 A.M., Nurse Practitioner #1 said that she was not notified of Resident #38's pain and would expect the nurse to assess a new onset or worsening of pain and would expect staff to call her. During a follow up interview on 10/7/22 at 12:10 P.M., Nurse Practitioner #1 said that Resident #38's pain is mostly on the right side by the Resident's foot and that she would increase Resident #38's [MEDICATION(S)] (a medication used to treat nerve pain) dose and order a [MEDICATION(S)] (a patch used to treat pain) for Resident #38's foot. During an interview on 10/11/22 at 1:15 P.M., Resident #38 said that the [MEDICATION(S)] has helped with his/her pain.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility and transfers, the Facility failed to ensure interventions from his/her plan of care related to level of staff assistance required with activities of daily living were implemented. On 8/29/19, Certified Nurse Aide (CNA) #1 sat Resident #1 on the edge of the bed to transfer him/her out of bed, without another staff member present to provide assistance, Resident #1 slipped off the edge of the bed and fell on to the floor. Resident #1 was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR). An Annual Fall Risk Assessment, dated 6/7/19, indicated Resident #1 was assessed to be at increased risk for falls. An Annual Minimum Data Set (MDS) Assessment, dated 6/14/19, indicated Resident #1 required extensive assistance of two staff members with bed mobility and transfers. Review of Resident #1's Plan of Care, dated 6/21/19, indicated he/she required two staff person assistance with bed mobility, positioning and transfers. The electronic Activity of Daily Living (ADL) Kardex (means of communicating residents needs to staff, to assure needs are met), utilized by the Certified Nurse Aides (CNAs), indicated Resident #1 required the assistance of two staff members with bed mobility and transfers. A Nurse Progress Note, dated 8/29/19, indicated Resident #1 fell during ADL care, and he/she was transferred to the Hospital Emergency Department for evaluation where he/she was diagnosed with [REDACTED]. The Surveyor interviewed CNA #1 at 9:54 [NAME]M. and at 1:30 P.M. on 9/17/19. CNA #1 said Resident #1 was placed on her assignment approximately 1 week prior to his/her fall. CNA #1 said she had not checked the electronic Kardex to determine the level of assistance Resident #1 required with transfers. CNA #1 said she thought Resident #1 was a one person assist with bed mobility and transfers, so she had not asked another staff member to assist her with transferring Resident #1 out of bed. CNA #1 said that on the morning of 8/29/19, she washed and dressed Resident #1 and sat him/her up on the edge of the bed. CNA #1 said she turned her back to reach for the wheelchair and as she was bringing the wheelchair closer, she heard a noise and said when she turned around she saw Resident #1 slipping off the bed. The Surveyor interviewed the Unit Manager at 11:45 [NAME]M. on 9/17/19, and Certified Nurse Aide (CNA) #2 at 12:15 P.M. on 9/17/19. The Unit Manager and CNA #2 said Resident #1 required the assistance of two staff members with bed mobility and transfers.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required an extensive assist of two staff members for transfers and bed mobility, the Facility failed to ensure that his/her safety was maintained and he/she was provided with adequate level of staff assistance during a transfer, to prevent an accident with injury. On 8/29/19, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 from his/her bed to a wheelchair, unassisted by another staff member. Resident #1 fell and sustained a fractured his/her left hip. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR). An Annual Fall Risk Assessment, dated 6/7/19, indicated Resident #1 was assessed as being at increased risk for falls related to diminished safety awareness, impaired mobility and problems with gait and balance. An Annual Minimum Data Set (MDS) Assessment, dated 6/14/19, indicated Resident #1 required an extensive assistance of two staff members with bed mobility and transfers. Review of Resident #1's Plan of Care, dated 6/21/19, indicated he/she required two staff person assistance with bed mobility, positioning and transfers. The electronic Activity of Daily Living (ADL) Kardex (means of communicating residents needs to staff, to assure needs are met), utilized by the Certified Nurse Aides (CNAs), indicated Resident #1 required the assistance of two staff members with bed mobility and transfers. A Nurse Progress Note, dated 8/29/19, indicated Resident #1 fell during ADL care, and he/she was transferred to the Hospital Emergency Department for evaluation, where he/she was diagnosed with [REDACTED]. The Surveyor interviewed CNA #1 at 9:54 [NAME]M. and at 1:30 P.M. on 9/17/19. CNA #1 said Resident #1 was placed on her assignment approximately 1 week prior to his/her fall. CNA #1 said she had not checked the electronic Kardex to determine the level of assistance Resident #1 required with transfers. CNA #1 said she thought Resident #1 was a one person assist with bed mobility and transfers, so she had not asked another staff member to assist her with transferring Resident #1 out of bed. CNA #1 said that on the morning of 8/29/19, she washed and dressed Resident #1 and sat him/her up on the edge of the bed. CNA #1 said she turned her back to reach for the wheelchair and as she was bringing the wheelchair closer, she heard a noise and said when she turned around she saw Resident #1 slipping off the bed. The Surveyor interviewed the Unit Manager at 11:45 [NAME]M. on 9/17/19, and Certified Nurse Aide (CNA) #2 at 12:15 P.M. on 9/17/19. The Unit Manager and CNA #2 said Resident #1 required the assistance of two staff members with bed mobility and transfers. The Hospital History and Physical Record, dated 8/29/19, indicated Resident #1 had a fractured left hip.

Based on observation, record review and interviews, the facility failed to ensure and maintain a safe environment to prevent a fall for 1 Resident (Resident #3), in a total sample of 23 and 2 Non-sampled Residents NS #1 and NS #2. Findings include: For Resident #3, the facility failed to ensure Resident supervision and maintenance of a safe working chair alarm on 1/3/14, resulting in an unwitnessed fall from a wheelchair that required the Resident to be sent to the emergency room for evaluation and surgical repair of a left fractured hip. Resident #3 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. Record review on 5/19/14 at 9:00 A.M,.indicated that the Resident had a fall on 1/3/14 approximately at 1:30 P.M. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE], indicated Resident #3 was severely cognitively impaired with short term and long term memory problems. The MDS also indicated that the Resident had fluctuating inattention (difficult following what was said), and disorganized thinking. The MDS coded the Resident as incontinent of bowel and bladder, and unsteady moving from a seated to a standing position. MDS Section G coded Transfer as: -Self performance as extensive assistance and required one person physical, -Assist to transfer from wheelchair to a standing position, -Used a wheelchair for ambulation, -Only able to stabilize with staff assistance. -Walking did not occur during the 7 day observation period. The Care Plan for Falls revised on 12/11/13 indicated the following: -Institute Fall Red Leaf Program, (facility fall prevention program). -Provide bed/chair alarm. -Provide/monitor use of wheelchair. -Lock brakes on chair before transferring and remind Resident to request assistance prior to ambulation. Review of Resident #3 's Fall Risk Assessment of 1/3/14 identified a score of 17 (10 or above = high risk for falls). On 1/3/14 (after the Resident's fall), additional interventions were added to the care plan: -Continue with bed and chair alarm and monitoring Resident. -Dependent on one physical assist for bed mobility. -Resident is non ambulatory and dependent for mobility in wheelchair. Review of the facility incident report dated 1/3/14 read: On January, 2014 at approximately 1:30 P.M., staff responded to Resident #3 who was sitting on the floor with his/her hands holding on to his/her wheelchair in the day room. His/her vital signs were Temperature 97.4, Pulse 78, Respirations 20 and Blood Pressure 130/82. A complete physical assessment was done and as the Resident was struggling to get up, he/she was able to move all extremities. There were no visible signs of injury or redness. He/she was assisted by 2 staff members and later went to bed for a nap. At approximately 3:00 P.M., the Resident complained of mild pain with a score of 3 (0 = low and 10 = high) that was relieved with Tylenol. The physician and Nurse Practitioner (NP) were called, but were not able to be reached. The Resident slept through the night, had lunch with family the next day with no issues noted. At 2:30 P.M.on 1/4/14, the Resident was assessed and was noted to have left hip pain and some swelling. The Resident was medicated and upon reaching the NP by phone an order was obtained and the Resident was transferred to an acute care facility for X-Rays of the left and right hips. Resident #3 was diagnosed and treated for [REDACTED]. On 5/19/14 at 10:00 A.M. review of the incident report indicated that the chair alarm was not working. Facility follow up investigation interview documents, dated 1/14/14, indicated that staff who were on duty on 1/3/14 identified that the chair alarm was checked and functioning at 5:30 A.M. and during the morning medication pass at 11:30 A.M. The Resident had been toileted prior to being in the day room. Further investigation interviews by the facility identified that 2 staff were at the nurses station doing paper work and one CNA who was in the dining room left to attend to another Resident. Although the day room is within visual distance to the dining room from the nurses station, the Resident fall was unwitnessed. The facility follow-up investigation correction plan included: -The removal of the chair alarm that Resident #3 was using, -A house audit of all bed and chair alarms were checked for function, and -Re-education of staff that there is to be one CNA in the dining room at all times that Residents are in the day room. On 5/19/14 at 11:00 A.M., interview with the Director of Nursing (DON) identified the investigation concluded that the chair alarm was not working at the time of the fall, and there were no staff in the dining room supervising the Resident. The DON stated that the facility policy is that a Certified Nursing Assistant (CNA) must be in the dining room when there are Residents in the room. On 5/14, 5/19 and 5/20/14 Surveyor #1 and Surveyor #2 observed during survey that there were always 2 CNA' s in the dining room when Residents were in there.