Every finding on record at Care One at Lexington

Based on record review and interviews the facility failed to ensure resident rights were maintained. Specifically, the facility failed to deliver mail from the US Postal Service on Saturdays, potentially impacting on the well-being of residents who are expecting mail. Findings include: Review of the facility's policy, dated revised May 2017, indicated the following: Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentiality 4. Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or the facility's post office box (including Saturday deliveries). During the resident group meeting conducted by the surveyor on 12/23/25 at 11:00 A.M., and attended by 17 residents, three active participants said mail is delivered Monday through Friday and that no one from staff delivers mail on Saturday. The participating residents said outside of the facility they received U.S. postal mail on Saturdays. During an interview on 12/23/25 at 12:55 P.M., the Activities Director said he is responsible for delivering resident mail. The Activity Director said he typically delivers the mail at the end of the day every Monday through Friday. The Activity Director said the mail delivered on Saturday from the U.S postal Service is delivered on Mondays. The Activity Director said the residents never brought it up to him about getting their mail delivered on Saturdays. During an interview on 12/24/25 at 8:53 A.M., the Administrator said mail delivery should not be any different and mail should be delivered on Saturdays.

Based on observation and interview, the facility failed to provide a clean and homelike environment on one (the [NAME] Unit) of four resident units. Findings include:Review of the facility policy titled Homelike Environment, dated February 2021 indicated: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The surveyor observed the following on the [NAME] Unit on 12/23/25 at 10:31 A.M.: room [ROOM NUMBER]: Red stains on radiator and on chair. Large bowing stained ceiling tile. Large gouge in bathroom door. Room27: Deep scratches in flooring near the bed. room [ROOM NUMBER]: Stained flooring near toilet. room [ROOM NUMBER]: Stained floor by toilet, basin of water catching leaking water from the sink. room [ROOM NUMBER]: Stained window shade, broken handle on nightstand drawer, visibly dirty overbed table.room [ROOM NUMBER]: Basin catching water in sink due to leak in faucet. Deep gouge in door to bathroom. Towel on the floor wrapped around toilet. room [ROOM NUMBER]: Peeling laminate on the W bed dresser. Towel on floor around toilet. room [ROOM NUMBER]: Partial stained ceiling tile in the bathroom.room [ROOM NUMBER]: Torn and visibly soiled fall mat with dirt and debris with exposed foam. room [ROOM NUMBER]: Long black scuff mark along closet doors.room [ROOM NUMBER]: Missing handle of top drawer in dresser by D bed. room [ROOM NUMBER]: Missing handle on D bed nightstand drawer, stained top of dresser for window bed. room [ROOM NUMBER]: Missing handles on first and second drawers for D bed dresser, long black scuff marks along closet doors. room [ROOM NUMBER]: Two ripped fall mats with exposed foam, scrape in door to bathroom. room [ROOM NUMBER]: Scrape in door to bathroom, stained ceiling tile in bathroom. During an interview on 12/23/25 at 11:12 A.M., Unit Manager #1 said environmental issues are relayed to the Maintenance Director verbally or on the TELS system. Unit Manager #1 said she was not aware of any environmental issues on the unit. During an interview on 12/23/25 at 2:01 P.M., the Administrator said she expects staff to report any environmental concerns to the Maintenance Director so they could be addressed.

Based on observation, record review and interview, the facility failed to ensure the physical environment accommodated the needs of one Resident (#90) out of a total of 31 sampled Residents. Specifically, the facility failed to provide Resident #90 with a bed that fit him/her appropriately. Findings include: Review of the facility's policy titled Accommodation of Needs dated March 2021 indicated: Policy Statement: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. 2. The resident's individual needs, and preferences, including the need for adaptive devices and modifications to the physical environment are evaluated upon admission and reviewed on an ongoing basis.3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom as well as the common areas in the facility. Resident #90 was admitted to the facility in July 2024 with diagnoses including stroke, vascular dementia and reduced mobility. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #90 is moderately cognitively impaired as evidenced by a score of 8 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #70 is dependent on staff for positioning and transfers. Additional review of the MDS indicated Resident #90 is 76 inches (6ft 3 inches) tall. During an interview on 12/22/25 at 9:08 A.M., the surveyor observed Resident #90 resting in bed with his/her ankles and feet hanging off the end of the bed. Resident #90 said that his/her feet and ankles have been sliding off the edge of the bed forever. When asked if staff were aware or if he/she had reported it, Resident #90 said nobody cares.On 12/22/25 at 11:13 A.M., the surveyor observed Resident #90 resting in bed with his/her ankles and feet hanging off the foot of the bed.On 12/23/25 at approximately 7:45 A.M., the surveyor observed Resident #90 resting in bed with his/her ankles and feet hanging off the foot of the bed.During an interview on 12/23/25 at 7:55 A.M., Unit Manager #2 said that Resident #90 is tall and slides down in his/her bed. Unit Manager #2 said that she put in a request a couple weeks ago for a longer bed for Resident #90 with the maintenance department. Unit Manager #2 showed the surveyor a text message requesting a longer bed for Resident #90 dated 12/4/25. During an interview on 12/23/2025 at 8:02 A.M., Nurse #1 said that Resident #90's feet have always hung over the edge of the bed for about a year.During an interview on 12/23/2025 at 8:11 A.M., Nurse #2 said that Resident #90 slides down his/her bed which results in his/her feet dangling off the end of the bed. Nurse #2 said it takes 2-3 staff to boost him/her back up, but he/she slides back down again. Nurse #2 said it's been an ongoing issue for a couple of months. During an interview on 12/23/2025 at 8:29 A.M., the Maintenance Director said he was not sure when the request for a longer bed for Resident #90 was placed but he/she would obtain a longer bed for him/her today (12/23/25). During an interview on 12/23/2025 at 12:25 P.M., Consultant Nurse #2 said that if a resident's bed does not fit him/her appropriately, a new one should be provided.

Based on interview and record review, the facility failed to ensure the grievance process was followed for one Resident (#70) out of a total of 31 sampled residents. Specifically, the facility failed to follow the grievance process and complete a grievance form after Resident #70 reported he/she was missing a robe. Findings include: Review of the policy titled Grievances/Complaints, Recording and Investigating dated April 2017 indicated: Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. Policy Interpretation and Implementation: 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. 5. The grievance officer will record and maintain all grievance and complaints on the Resident Grievance Complaint log. The following information will be recorded and maintained in the log: The date grievance/complaint was received, the name and room number of the resident filing the grievance/complaint (if available) The Resident Grievance/Complaint investigation report form will be filed with the administrator within five working days of the incident. 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 working days of the filing of the grievance or complaint. Resident #70 was admitted to the facility in September 2025 with diagnoses including altered mental status and essential hypertension. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #70 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam. During an interview on 12/22/25 at 8:47 A.M., Resident #70 said that he/she had a bathrobe that went missing from his/her room. Resident #70 said he/she brought it to the attention of staff, but Unit Manager #2 said there's nothing I can do about it. Resident #70 said staff did not offer a grievance form for him/her to complete.Review of grievance book/log failed to include any grievance related to missing items for Resident #70.During an interview on 12/23/25 at 7:54 A.M., Unit Manager #2 said that she had heard about Resident #70's missing robe about a month ago and that she spoke with the Resident's Health Care Proxy, who reported he/she was missing a robe. Unit Manager #2 said she did not complete a grievance form, but she should have.During an interview on 12/23/25 at 9:51 A.M., the Administrator said she reviews all grievances and was not aware of any concerns for Resident #70. The Administrator said that a grievance should have been completed for Resident #70 after he/she reported he/she had a missing robe.

Based on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards for one Resident (#55), out of 31 total sampled residents. Specifically, for Resident #55 the facility failed to ensure that nursing removed the correct medication patch during the medication pass observation. Nurse #4 removed a clonidine patch (medicated patch applied once a week used to treat hypertension) instead of a nicotine patch (medicated patch applied once a day used to treat nicotine cravings). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated that medications are administrated in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. Resident #55 was admitted to the facility in December 2025 with diagnoses including urine retention, alcohol dependence, hypertension, and chronic obstructive pulmonary disorder. Review of Resident #55's most recent Minimum Data Set (MDS) assessment, dated 12/17/25, indicated moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of 15. Review of Resident #55's physician's orders, dated 12/10/25, indicated:- clonidine transdermal patch weekly 0.2 milligrams (mg)/24 hour, apply 1 patch transdermally in the morning every Monday for hypertension and remove per schedule.- nicotine transdermal patch 24 Hour 14 mg/24 hour, apply 1 patch transdermally in the morning for smoking cessation and remove per schedule. Review of Resident #55's Medication Administration Record, dated 12/22/25, indicated nursing administered/applied a new clonidine patch to his/her left arm. On 12/23/25 at 8:41 A.M., during the medication administration pass the surveyor observed Nurse #4 remove a peach-colored patch from Resident #55's left arm. The patch was dated 12/22/25. Nurse #4 crumpled the peach-colored patch, and she put the patch in the trash. Nurse #4 then applied a nicotine patch that was clear (not peach-colored) on Resident #55's right chest wall. The surveyor asked Nurse #4 what patch she had removed from Residents #55's left arm, and she said that it was the old nicotine patch. On 12/23/25 at 8:46 A.M., the surveyor reobserved the peach-colored patch that Nurse #4 removed from Resident #55's left arm. The patch was labeled clonidine 0.2mg/day. On 12/23/25 at 1:24 P.M., the surveyor, Nurse #4, and the Facility Educator (FE) were unable to locate Resident #55's clonidine patch that was documented as applied to the left arm on 12/22/25. Nurse #4 said that she was unaware she removed the clonidine patch from Resident #55's left arm during the medication administration observation, and she said that she didn't realize that Resident #55 had a clonidine patch ordered. During an interview on 12/23/25 at 1:25 P.M., the FE said that Nurse #4 should have verified the correct mediation patch before removing Resident #55's clonidine patch. During an interview on 12/23/25 at 2:06 P.M., Nurse Consultant #2 said that Nurse #4 should have verified that she removed the nicotine patch during the medication administration.

Based on observations and interviews, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment for one Resident (#46), out of 31 total sampled residents. Specifically, for Resident #46 the facility failed to remove a portable oil-filled radiator heater from his/her room. Findings include:Review of the facility policy titled, Electrical Appliances, dated as revised January 2019, indicated that portable space heaters are not allowed in resident areas. Resident #46 was admitted to the facility in December 2024 with diagnoses including Diabetes, chronic pain, and anemia. Review of Resident #46's most recent Minimum Data Set (MDS) assessment, dated 9/26/25, indicated intact cognition as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. On 12/22/25 at 8:16 A.M., the surveyor observed Resident #46 lying on his/her bed with an electric heater next to his/her bed. The surveyor also observed that next to the heater was an electric power strip. During an interview on 12/23/25 at 9:07 A.M., the Maintenance Supervisor said that electric heaters are not allowed to be used in resident's rooms and was going to remove it immediately. He said that the risk of having an electric heater in a Resident's room was that it could cause a fire. During an interview on 12/23/25 at 9:22 A.M., the Maintenance Supervisor said that when he went to Resident #46's room he found that the electric heater had already been removed by another staff member. During an interview on 12/24/25 at 7:46 A.M., Unit Manager #3 said she had removed the electric heater when she had noticed it in Resident #46's room on 12/22/25. She said that there was a risk of causing a fire if an electric heater was in a resident's room. She said she had not seen the electric heater in Resident #46's room before. During an interview on 12/24/25 at 7:50 A.M., Certified Nursing Aide #2 said she had never seen the electric heater in Resident #46's room before. During an interview on 12/24/25 at 7:45 A.M., Resident #46 said that his/her son had brought in the heater to use in the summer when the air conditioning had been too cold, but that since the heat had been turned on in the building, he/she had been warm enough and no longer needed to use the electric heater. During an interview on 12/24/25 at 8:01 A.M., the Administrator said she was not aware that Resident #46 had an electric heater and his/her room and that the facility has a policy that electric heaters are not to be used in residents' rooms due to risk of fire.

Based on observation, record review and interview, the facility failed to ensure food items were stored appropriately in the reach-in refrigerator in the main kitchen. Findings include: Review of the facility's policy titled, Food Receiving and Storage undated, indicated: Food shall be received and stored in a manner that complies with safe food handling practices. 1. All Foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded. On 12/22/25 at 6:54 A.M., the surveyor observed the following in the reach-in refrigerator during the initial kitchen walk through:-Two undated and unlabeled sandwiches. -One sandwich labeled Chicken dated use by 12/21/25.-19 containers of pudding, undated and unlabeled. -One sandwich labeled Chicken Salad dated used by 12/19/25.-One sandwich labeled Peanut Butter dated use by 12/15/25. During an interview on 12/22/25 at 11:32 A.M., the Food Service Director (FSD) said all items should be dated and labeled in the refrigerator. The FSD said that the pudding cups had been used for the previous night's dinner meal and sandwiches should be discarded after three days.

Based on record review, interview and observation, the facility failed to ensure complete and accurate medical records for two Residents (#34, #51) of 31 sampled residents. Specifically:For Resident #34, the facility failed to document weekly skin checks ordered by the physician.For Resident #51, the facility failed to accurately transcribe physician treatment orders. Findings include: Review of the Charting and Documentation policy dated July 2017 indicated: Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #34 was admitted to the facility in December 2025 and had diagnoses which included heart disease and anxiety disorder. Review of Resident #34's baseline care plan dated 12/12/25 indicated he/she was at risk for skin breakdown and that staff should regularly assess the Resident's skin. Review of Resident #34's medical record on 12/22/25 indicated Facility staff had not yet completed the Minimum Data Set assessment or the Brief Interview for Mental Status examination. Review of Resident #34's Clinical Nursing admission assessment dated [DATE] indicated staff assessed his/her skin on this date and bruising was noted on both arms and thighs. Review of Resident #34's physician order dated 12/13/25, indicated: - Weekly skin check, complete skin check under Forms tab every evening shift every Saturday. Review of Resident #34's Treatment Administration Record indicated weekly skin checks were not completed on 12/13/25 and 12/20/25, as ordered by the physician. Review of the Resident's medical record indicated there was no reference to staff attempting to provide skin checks on these dates. On 12/22/25 at 8:49 A.M., the surveyor observed bruising on Resident 34's forearms and wrists. The Resident said he/she was unsure if the bruises were caused by a fall at home, or if he/she sustained these at the facility. The Resident said he/she did not know if staff had assessed his/her skin since admission to the facility. During an interview with the Infection Preventionist and Consulting Nurse #1 on 12/23/25 at 11:00 A.M., they said they were unable to find documentation in Resident #34's medical record to indicate staff attempted skin assessments on 12/13/25 or 12/20/25. Review of a written statement provided to the surveyor by Nurse #3, who was assigned to complete Resident #34's skin checks on 12/13/25 and 12/20/25, indicated the Resident was very anxious and refused skin checks on these dates. The statement did not reference if Nurse #3 documented these refusals in the medical record. 2. Resident #51 was re-admitted to the facility in October 2025 with diagnoses including chronic obstructive pulmonary disease and traumatic hemorrhage of the cerebrum. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #51 is moderately cognitively impaired as evidenced by a score of 9 out of a possible 15 on the Brief Interview for Mental Status Exam. a. Review of Resident #51's Dermatology Report dated 12/10/25 indicated: Impression/Plan: Scabies; a scabies prep was performed on the left palmar ring finger, showing mites and stool. Plan: Ivermectin 3 mg tablet, take 6 pills at once then again after 24 hours and repeat again after 8 days. Permethrin 5% topical cream: apply neck down to feet, Wash off after 12 hours. Repeat every 7 days for 3 weeks. Review of physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated December 2025 failed to indicate permethrin was applied. During an interview on 12/23/25 at 8:14 A.M., the Infection Preventionist said that Resident #51 was treated for the scabies per the orders from the dermatologist, but the order was not appropriately transcribed into the clinical record. b. Review of Resident #51's current physician orders indicated the following: apply to whole body for itch, 11/19/25. The order failed to indicate what specifically staff should be applying to Resident #51's body. Review of the Medication Administration Record and Treatment Administration record for November 2025 and December 2025; indicated nursing staff signed off on the above order. During an interview on 12/23/25 at approximately 9:30 A.M., Unit Manager #1 said that the order should have specifically identified what treatment staff should be applying to Resident #51 and nursing staff should have attempted to clarify the order with the physician.

Based on interview and observation, the facility failed to ensure it provided a homelike environment on the [NAME], [NAME], Minuteman, and [NAME] units. Findings include: 1. On 12/27/24 at approximately 2:15 P.M., on the [NAME] unit, the surveyor observed: - Cracked plastic paper towel holders in rooms #27, #28, and in the hallway men's room. - Sagging and broken ceiling tiles in rooms #26, #32, #33 and #35. - Worn wooden side dresser in room [ROOM NUMBER], worn dresser in room [ROOM NUMBER] - Broken bathroom wall measuring approximately 8 x 8 in room [ROOM NUMBER]. 41019 2. During rounds on the [NAME] unit on 12/30/24 at 11:30 A.M., the surveyor observed:: - room [ROOM NUMBER] had cracks along the wallpaper behind the bed closest to the door and along the wall surrounding a communication board. - room [ROOM NUMBER] had a call light device hanging off of the wall by an electrical cord. - room [ROOM NUMBER] had a closet door falling off the hinges. 48671 3. On 12/27/24 at approximately 8:36 A.M., on the Minuteman unit, the surveyor observed: -One four drawer dresser with patches of missing laminate covering peeled off in room [ROOM NUMBER]. -One side dresser with patches of missing laminate covering in room [ROOM NUMBER]. -Large chipped off wood and scratched white paint located on the door trim of room [ROOM NUMBER]. -Sagging ceiling tile trim located on the [NAME] Unit across from the nurses station near the exit sign. -Two Cracked plastic wall mounted hand sanitizer units located in the hall outside of room [ROOM NUMBER] and room [ROOM NUMBER]. The units were not working and failed to dispense hand sanitizer when the surveyor placed a hand under the sensors. On 12/27/24 at approximately 11:54 A.M., on the [NAME] unit, the surveyor observed: -One plastic wall mounted hand sanitizer unit located in the hall outside of dining room. The unit was not working and failed to dispense hand sanitizer when the surveyor placed a hand under the sensor. During an interview with the Maintenance Director on 12/30/24 at 12:27 P.M., he said there is a maintenance tracking program to detail and track items that need repair or replacement. The Maintenance Director said he conducts weekly rounds on each of the units and staff are responsible for reporting additional concerns. He said he was aware of some of the environmental issues on the [NAME] unit, but staff had not reported others, including the broken paper towel holders and broken bathroom wall. During an interview with the Maintenance Director on 12/30/24 at 9:15 A.M., he said hand sanitizer units that are broken or not working should be reported or replaced when they are identified. During an interview with the Administrator on 12/30/24 at 1:00 P.M., he said any broken equipment or equipment that is not working needs to be reported to maintenance and fixed or replaced.

Based on observation and interview the facility failed to handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff did not handle ready-to-eat food with their bare hands. Findings include: Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revised November 2022, indicated, but was not limited to, the following: - Contact between food and bare (ungloved) hands is prohibited. - Gloves are worn when directly touching ready-to-eat food. The surveyor made the following observations during the tray line observation on 12/27/24 at 11:36 A.M.: - The cook used his bare hands to transfer four out of the first four ready-to-eat baked potatoes from the steam table onto plates to be served to the residents. During an interview on 12/27/24 at 11:41 A.M., the Food Service Director (FSD) said the cook should not be touching ready-to-eat potatoes with his bare hands and that all the potatoes the cook touched must be discarded.

Based on record review, interview and observation, the facility failed to ensure accurate documentation of the clinical record for three Residents (#17, #52, #392) of 37 sampled residents. Specifically: 1. For Resident #52, the facility documented compression stocking were applied when they were not. 2. For Resident #17, the facility documented heel protectors were applied when they were not. 3. For Resident #392, the facility failed to ensure nursing obtained a physician's order for a lidocaine (topical prescription medicated patch used for pain) patch that included the location, and the facility failed to ensure that nursing consistently documented the location where the lidocaine patch was applied. 1. Resident #52 was admitted to the facility in November 2022, and has active diagnoses which include congestive heart failure, bilateral leg edema and dementia. Review of Resident #52's Minimum Data Set assessment dated [DATE], indicated he/she was dependent on staff for all lower body dressing and putting on/taking off footwear. The Resident had a Brief Interview for Mental Status Score of 3, indicating severe cognitive impairment. Review of Resident #52's care plan dated 12/29/22, indicated he/she was at-risk for alteration in skin integrity related to impaired mobility and bilateral edema. Interventions included: - TED stockings (compression stockings) as ordered. Review of Resident #52's physician order dated 11/9/23 indicated: - [NAME] stockings on morning and off at HS (nighttime). On 12/26/27 at 2:00 P.M., 12/27/24 at 8:55 A.M., and 10:05 A.M., the surveyor observed Resident #52 lying in bed and not wearing compression stockings. Review of Resident #52's Medication Administration Record (MAR) dated December 2024, indicated: - Apply TED stockings at 6:00 A.M. and remove in the evening. Staff documented compression stocking were applied and removed on a daily basis throughout the month, including 12/26/24 and 12/27/24. During an interview with Certified Nurse Aide (CNA) #2 on 12/27/24 at 8:57 A.M., she said she had worked with Resident #52 for many months and had never known him/her to wear compression stockings. CNA #2 said she had not received instruction from licensed nurses to apply compression stocking to his/her legs. During an interview with Nurse #3 on 12/27/24 at 9:05 A.M., he said Resident #52 did not wear compression stockings and he was unaware that the Resident had a physician's order for TED/compression stockings. Nurse #3 and the surveyor reviewed Resident #52's Medication Administration Record dated December 2024, and saw staff had documented they applied and removed compression stockings daily. Nurse #3 said the documentation was inaccurate because Resident #52 did not wear compression stockings. During an interview with the Director of Nurses (DON) on 12/27/24 at 10:52 A.M., she said a physician's orders for compression stockings should be followed. The DON said staff should not be documenting that compression stockings were applied when they were not. 2. Resident #17 was admitted to the facility in December 2016, and has diagnoses which include diabetes and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that on the Brief Interview for Mental Status exam Resident #17 scored a 12 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #17 had no behaviors of rejecting care and was dependent on staff for lower body dressing. Review of the current physician orders indicated the following: - Heel protector boots on at all times, may remove for transfers, start date 8/13/24. Review of the most recent Nurse Practitioner progress note, dated 12/11/24, indicated: - Peripheral vascular disease: status post left calcinatory - healed. - Continue protective boots daily. Review of the December 2024 clinical progress notes failed to indicate Resident #17 refused to wear heel protector boots. Review of the Certified Nursing Assistant (CNA) task documentation failed to indicate Resident #17 displayed any behavior of rejecting care in the past 14 days. Review of the current Diabetes care plan included the following intervention: - Diabetic foot care, started 12/28/16. Review of the current Activities of Daily Living (ADL) care plan included the following intervention: - Extensive Assist with daily bathing, grooming, dressing. Dependent when tired, dated as revised 3/15/21. During an observation and interview on 12/26/24 at 8:43 A.M., the surveyor observed Resident #17 in bed with both heels resting flat on the mattress. Two blue boots were located across the room on the Resident's wheelchair. Resident #17 said the boots were supposed to be put on by the staff but had not been. On 12/27/24 at 8:11 A.M., the surveyor observed Resident #17 asleep in bed. A bootie was on Resident #17's right foot and his/her left foot was flat on the mattress, with no heel protection. Another bootie was observed across the room on the Resident's wheelchair. On 12/27/24 at 10:18 A.M., the surveyor observed Resident #17 in bed. A bootie was on Resident #17's right foot and his/her left foot was flat on the mattress, with no heel protection. The other bootie was observed across the room on Resident #17's wheelchair. A sign posted on the wall behind the Resident's bed indicated blue multipodus boots must be donned at all time (sic). During an interview and observation on 12/30/24 at 8:23 A.M., Resident #17 was lying in bed, awake. The Resident was not wearing heel protector boots on either foot. The Resident said he/she had not worn a heel protector boot on the left foot while in bed for many months. The Resident said she used to wear a boot on the left foot at night, but that boot was lost, and staff had replaced it with a boot that did not fit. The Resident said staff eventually stopped applying the left boot. During an interview with Unit Manager #1 on 12/30/24 at 8:33 A.M., she said she had been working with Resident #17 for several years, and the Resident had not worn heel protection on the left foot for many months. Unit Manager #1 said she was unaware there was a physician's order for bilateral heel protectors. On 12/30/24 at 8:39 A.M., the surveyor and Unit Manager #1 entered Resident #17's bedroom and observed that the Resident was awake, lying in bed. Resident #17 was not wearing heel protectors on either foot. Across the room a single heel protector was located on a wheelchair. During an interview with CNA #2 on 12/30/24 at approximately 9:00 A.M., she said she was unaware that Resident #17 was supposed to always wear a heel protector on the left foot. CNA #2 said she had not received instruction from licensed nursing staff to apply heel protection to the left foot. During an interview with the Director of Nurses (DON) on 12/27/24 at 10:52 A.M., she said physician's orders should be followed. The DON said staff should not be documenting that an order had been completed when it had not. 44095 3. Review of the facility policy, Administering Medications, dated as revised 5/16/24, indicated that medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #392 was admitted to the facility in December 2024, with diagnoses including diabetes, chronic pain, and colitis. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/21/24, indicated that Resident #392 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 12/27/24 10:54 A.M., the surveyor observed Nurse #6 prepare and administer a lidocaine patch to Resident #392. Nurse #6 said that there was no location for the lidocaine patch as part of the order. Resident #392 said that the nurses applied it on all different places including the back and shoulder. Review of Resident #392's physician's order, dated 12/14/24, indicated: - Lidocaine Patch 5% apply to skin topically, one time a day for pain management. Apply for only 12 hours in a 24 hour period. May dose - 3 patches. External use only and remove per schedule. Further review of the order failed to indicate a location to apply the patch. Review of Resident #392's Medication Administration Record (MAR), dated December 2024, indicated nursing staff administered Resident #392 his/her lidocaine patch between 12/15/24 and 12/27/24 (13 times), without identifying a location. Further review of the MAR indicated that the location of administration was not recorded. During an interview on 12/30/24 at 10:03 A.M., Unit Manager #2 reviewed Resident #392's order for lidocaine patches and she said that the order was incomplete and required a site location to apply the patch. During an interview on 12/30/24 at 12:19 P.M., the Director of Nursing said lidocaine patch orders should have a location as part of the order.

Based on record review, interview and observation, the facility failed to follow infection control procedures. Specifically: 1. The facility failed to ensure 2 of 2 nurses cleaned blood glucose meters according to infection control practices. 2. The facility failed to ensure staff wore complete personal protective equipment in rooms designated as requiring enhanced barrier precautions. 3. The facility failed to ensure staff conducted proper handwashing and glove use. 4. The facility failed to ensure it used unexpired hand sanitizer. 44095 Review of the facility policy, Blood Glucose Monitoring, dated as revised [DATE], indicated: Disinfect the meter before and after each use, or when the monitor is visibly soiled as follows: - Use Super Sani-Cloth Germicidal Disposable Wipe (or other commercially prepared pre-moistened wipe which meets CDC guidelines) to wipe down the meter using caution not to get liquid in the test strip and key code ports of the meter - If blood is visibly present on the meter, a 2nd Sani-Cloth(R) germicidal Disposable Wipe must be used. - If the Super-Sani Cloth (or other commercially prepared pre-moistened wipe which meets CDC guidelines) is unavailable, use a 1:10 sodium hypochlorite solution and a soft cloth. 1a. On [DATE] at 8:33 A.M., the surveyor observed Nurse #5 obtain a black case from the medication cart, containing a glucometer, several lancets, alcohol prep pads, 2 x 2 pads, and insulin needle tips for pen injectors. Nurse #5 entered the Resident's room and placed the black case directly on top of his/her uncleaned overbed table. Nurse #5 obtained the Resident's blood sugar and immediately put the glucometer back in the black case without cleaning it, and potentially contaminating the contents of the black case. Nurse #5 then returned the case to the medication cart. During an interview on [DATE] at 9:25 A.M., Nurse #5 said he was not sure how and when to clean glucometers. During an interview on [DATE] at 2:26 P.M., the Director of Nursing said nursing should clean the glucometer with germicidal wipes after use. 1b. On [DATE] at 9:54 A.M., the surveyor observed Nurse #6 gather supplies to obtain a blood sugar. Nurse #6 obtained a blood sugar from a Resident and then she cleaned the glucometer with an alcohol wipe (not a germicidal wipe) and placed the glucometer back into the medication cart, potentially contaminating the contents of the drawer. During an interview on [DATE] at 9:58 A.M., Nurse #6 said she cleaned the glucometer with the alcohol wipe and said she did not have any germicidal wipes. During an interview on [DATE] at 2:26 P.M., the Director of Nursing said nursing staff should clean the glucometer with germicidal wipes after each use. 45763 2. Resident #38 was admitted to the facility in [DATE], with a diagnosis of malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating moderate cognitive impairment. Further review of the MDS indicated the Resident received 51% or more of his/her calories through a feeding tube. Review of Resident #38's physician orders indicated the following: - JTube (jejunostomy, a surgically created opening in the abdomen terminating in the jejunum, a portion of the small intestine, primarily utilized to provide nutritional formula): NSW (normal saline wash) pat dry apply split gauze every day shift - initiated [DATE]. - Enteral feed (feeding provided via a feeding tube, such as through a jejunostomy) - initiated [DATE]. On [DATE] the surveyor made the following observations on the [NAME] unit: At [DATE] at 10:12 A.M., the surveyor observed a staff member providing toileting assistance to Resident #38 in his/her bathroom. There was no enhanced barrier precaution signage outside of the Resident's room and the staff member was not wearing a gown. During a continuous observation from 11:16 A.M. to 11:25 A.M., the surveyor observed a nurse taking Resident #38's vitals in his/her room, including a blood pressure reading obtained by wrapping a blood pressure cuff around the Resident's arm. There was no enhanced barrier precaution signage outside of the Resident's room and the nurse was not wearing a gown or gloves. The nurse then took the vital signs machine out of Resident #38's room and into another resident's room and proceeded to take the vitals of another resident, including a blood pressure reading obtained by wrapping the same blood pressure cuff previously used on Resident #38. The nurse did not disinfect the vital signs machine or blood pressure cuff between resident use. The surveyor also observed that there were no disinfecting wipes in the spot designated for disinfecting wipes on the vital signs machine. During an interview on [DATE] at 11:51 A.M., the Director of Nursing (DON) said she would expect a resident who is receiving enteral nutrition to be on enhanced barrier precautions and that she would expect staff to wear gloves and a gown while providing high contact activities such as providing toileting assistance and taking vitals. The DON said she expected staff to sanitize/disinfect the vital signs machine, including the blood pressure cuff, in between resident use. 48671 3. On [DATE] at 8:29 A.M., the surveyor observed a Certified Nursing Assistant (CNA) on the Minuteman unit exit a resident's room, identified as requiring transmission-based precautions. The CNA wore two gloves and carried a plastic bag of soiled lined. The CNA walked down the hall and used one gloved hand to open the dirty linen container and placed the bag inside. potentially contaminating the lid. The CNA removed both gloves, and without washing her hands, opened the lid to the trash container located in the hall, potentially contaminating the lid. During an interview on [DATE] at 9:09 A.M., the Director of Nursing (DON) said staff should not wear gloves in the hallway and said gloves should be removed properly. The DON said staff are expected to use hand sanitizer when entering and exiting resident rooms, and after doffing gloves. 4. On [DATE] at approximately 8:36 A.M., the surveyor observed the following on the Minuteman Unit: - One wall mounted hand sanitizer unit with an expiration date of [DATE], located in the hall outside room [ROOM NUMBER]. - One wall mounted hand sanitizer unit with an expiration date of [DATE], located in the hall outside room [ROOM NUMBER]. - One wall mounted hand sanitizer unit with an expiration date of [DATE], located in the hall outside room [ROOM NUMBER]. - One wall mounted hand sanitizer unit with an expiration date of [DATE], located in the hall outside room [ROOM NUMBER]. On [DATE] at approximately 8:36 A.M., the surveyor observed the following on the [NAME] Unit: - One wall mounted hand sanitizer unit with an expiration date of [DATE], located in the hall outside of the dining room. During an interview on [DATE] at 9:09 A.M., the Director of Housekeeping said hand sanitizer needs to be replaced if expired. During an interview on [DATE] at 1:00 P.M., the Administrator said hand sanitizer should not be in use if expired and said housekeeping is responsible for replacing and checking the wall mounted units. 41105 5. On [DATE] at 8:02 A.M., on the Minuteman Unit, the surveyor observed a sign at the door of a resident room that indicated, STOP ENHANCED BARRIER PRECAUTIONS. Instructions on the sign included gloves and gown for high contact care. A Certified Nursing Assistant (CNA) exited the room wearing gloves on each hand and carrying a soiled brief in the left hand. The CNA was not wearing a gown. With the gloved right hand, the CNA picked up the cover of a trash bin, potentially contaminating its surface, and placed the soiled brief inside. The CNA then removed the gloves, threw them into the trash can, and re-entered the room without cleaning her hands, potentially contaminating the room.

Based on interview and observation, the facility failed to ensure it had secured hallway handrails on the [NAME] and Minuteman units. Findings include: 48671 Minuteman Unit On 12/27/24 at approximately 9:15 A.M., the surveyor observed: - Handrail end cap detached from rod and metal not secure, located in the hallway near rooms 223-224. On 12/27/24 at approximately 9:37 A.M., the surveyor observed: - Handrail end cap detached and no longer attached to the abutting the wall, located in hallway near room [ROOM NUMBER]. [NAME] Unit On 12/30/24 at approximately 8:58 A.M., the surveyor observed: - Handrail end cap detached and no longer attached to the abutting wall. Another end cap was missing and metal screws were exposed located, located near the sprinkler room. -Handrail end cap detached, and not attached to the wall, located in the hallway near the dining room. During an interview with Maintenance Staff #1 on 12/30/24 at 9:03 A.M., he said staff will report broken handrails to us verbally or by using the online TELS program. Review of the online TELS program failed to indicate any information related to broken, loose or missing handrails in the facility. During an interview with the Maintenance Director on 12/30/24 at 9:09 A.M., he said loose handrails have been an ongoing issue in the facility because they become loose and spin off. He continued to say that he noticed the missing end cap about a week ago and said it was thrown out. The Maintenance Director said he would need to order new ones if he does not have any replacement parts in storage. The Maintenance Director said there have been no staff notifications of broken or missing handrails. The Maintenance Director then showed the surveyor a preventative maintenance worksheet that he uses to track issues he identifies in the facility and said he conducts weekly rounds to track things that need to be fixed. Review of the worksheet dated 10/31/24 indicated, handrails needed to be fixed but failed to indicate a completed /closed date as indicated on the form, and was left blank. The Maintenance Director said he did not have the notes from the audit that was done last week because he asked another staff member to complete them and has not received the notes yet. He said the handrails should be fixed when identified and said loose or broken handrails are a safety risk if not secured properly. During an interview with the Administrator on 12/30/24 at 12:57 P.M., he said he would expect any detached, loose, broken or missing handrails to be reported when noticed and fixed or replaced right away.

Based on observation, interview and record review the facility failed to provide a dignified dining experience for one Resident (46) out of a total sample of 37 residents. Findings include: The facility policy titled Dignity, revision date 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. - Individual needs and preferences of the resident are identified through the assessment process. - When assisting with care, residents are supported in exercising their rights. For example, residents are: Provided with a dignified dining experience. Resident #46 was admitted to the facility in October 2019 and has diagnoses that include Cerebral Palsy (condition that affects movement and posture), Parkinson's disease, muscle weakness, tremors, lack of coordination, feeding difficulties, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/29/24, indicated that on the Brief Interview for Mental Status exam Resident #46 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #46 requires setup assistance with eating. Review of the current care plans for Resident #46 indicated but was not limited to: Focus: risk for malnutrition r/t (related to) PMHx (past medical history) notable for tremors, Cerebral Palsy, GERD (gastro esophageal reflux disease) and depression - need for adaptive equipment with meals, dated as initiated 10/10/19. Interventions include: - Encourage and assist as needed to consume foods and/or supplements and fluids offered at and between meals, dated as initiated 10/10/19. On 12/27/24 at 9:20 A.M., the surveyor observed Resident #46 sitting in his/her wheelchair in the bedroom doorway, the over bed table was in front of the Resident. At 9:22 A.M., a staff member delivered the breakfast tray, removed the lid from the oatmeal, peeled opened the cranberry juice, opened the container of milk, and exited the room. The surveyor observed the Resident unsuccessfully trying to adjust him/herself in the wheelchair while holding onto a weighted utensil and attempting to scoop scrambled eggs into his/her mouth. The Resident was unable to gather food onto the utensil. The Resident pushed the tray table forward and lowered his/her head to the breakfast plate and began placing his/her mouth onto the plate and using his/her tongue and hand to eat the scrambled eggs off the lip plate. The Resident repeated this action, and the scrambled eggs fell on to the Resident's shirt, pants, wheelchair, and floor. The Resident attempted to pick up the cranberry juice and his/her hand was shaking and spilling, and juice spilled onto the plate of scrambled eggs and pastry. The Resident unsuccessfully attempted to pick up a small, open container of milk and was shaking and spilled the milk onto the scrambled eggs and pastry. Milk spilled onto the plate, the breakfast tray, on the Resident's clothing and floor. Resident #46 tried picking up the bowl of oatmeal with two hands and to pour oatmeal into his/her mouth but was shaking and had a hard time keeping the bowl to his/her mouth and was able to get only a little oatmeal out of the bowl. The surveyor asked the Resident if he/she was offered any help from staff during meals and the Resident said No. When asked if he/she would like some help Resident #46 said Yes. Throughout the breakfast meal observation, staff did not check in on Resident #46. On 12/27/24 at 1:22 P.M., the surveyor observed Resident #46 sitting in his/her wheelchair in the doorway, the overbed table was in front of the Resident. At 1:29 P.M., a staff member delivered the lunch tray, removed lids from cups and exited the Resident's room. The surveyor observed Resident #46 attempting to eat the lunch meal and had difficulty bringing the juice cup to his/her mouth. The Resident's hands were shaking, and juice spilled from the container. The surveyor remained in the hall outside the Resident's room and no staff checked in on Resident #46 throughout the lunch meal. The Resident was visible through the bedroom doorway. During an interview on 12/30/24 at 8:27 A.M., Nurse #14 said Resident #46 is set-up only for meals but needs help sometimes with eating because he/she can't always keep the food on the spoon or fork because of his/her tremors. Nurse #14 said staff will go in and offer to help during meals just to make sure he/she can eat what is served. During an interview on 12/30/24 at 8:39 A.M., Unit Manager #1 said Resident #46 likes to do things by him/herself and won't always allow staff to help. Unit Manager #1 said staff should be offering to help and check in on the Resident during meals to see if he/she is able to eat because he/she has bad tremors and can't control movements. During an interview on 12/30/24 at 1:38 P.M., the Director of Nursing (DON) said staff should not be dropping off meal trays and leaving Resident #46 without ensuring he/she is able to access the meal and able to eat. The DON said staff should be checking in on Resident #46 and encouraging him/her to eat during the meal and offering assistance if needed. The DON said if the Resident refuses the staff are still expected to offer and check in with the Resident during meals.

Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for two Residents (#4 and #139) out of a total sample of 37 residents. Findings include: 1. Resident #4 was admitted to the facility in July 2019 with diagnoses including dementia, bipolar disorder, and anxiety disorder. Review of the facility document titled Documentation Survey Report v2 (where Certified Nurse's Aides document level of assist provided each shift and where that level of assist required by residents, is used to complete the MDS), dated [DATE] indicated that Resident #4 required the following: - Eating: substantial/maximum assist. - Oral hygiene: maximum assist/dependent. - Upper body dressing: maximum assist/dependent. Review of the MDS dated [DATE] indicated the following; - Eating: supervision/touching assistance. - Oral hygiene: partial/moderate assistance. - Upper body dressing: partial/moderate assistance. Review of the facility document titled Documentation Survey Report v2 dated October 2024 indicated that Resident #4 required the following: - Oral hygiene: Dependent. Review of the MDS dated [DATE] indicated the following; - Oral hygiene: Substantial/maximal assistance. During an interview on 12/30/24 at 10:53 A.M., MDS Nurse #1 said that the MDS should reflect what the daily documentation, completed by the CNAs, indicated for the level of assistance the resident required. 2. Resident #139 was admitted to the facility in September 2024 with diagnoses including cellulitis, diabetes, and malnutrition. Review of the progress notes dated 10/6/24 indicated Resident #139 was discharged home with medications and family. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #139 was discharged to an acute care hospital. During an interview on 12/30/24, at 10:15 A.M., MDS Nurse #1 said that the MDS was not coded correctly and should have accurately reflected Resident #139 discharged location.

Based on record review, interview and observation, the facility failed to ensure care plan implementation for four (Resident #52, #17, 442, and #46) of 37 sampled residents. Specifically: 1. For Resident #52, the facility failed to implement the physician order for compression stockings. 2. For Resident #17, the facility failed to implement the physician order for heel protectors. 3. For Resident #442, the facility failed to develop a care plan for eating assistance. 4. For Resident #46, the facility failed to develop a comprehensive falls care plan. Findings include: 1. Resident #52 was admitted to the facility in November 2022, and has active diagnoses which include chronic congestive heart failure, bilateral leg edema and dementia. Review of Resident #52's Minimum Data Set assessment dated [DATE], indicated he/she was dependent on staff for all lower body dressing and putting on/taking off footwear. The Resident had a Brief Interview for Mental Status Score of 3, indicating severe cognitive impairment. Review of Resident #52's care plan dated 12/29/22, indicated he/she was at-risk for alteration in skin integrity related to impaired mobility and bilateral edema. Interventions included: - TED stockings (compression stockings) as ordered. Review of Resident #52's physician order dated 11/9/23, indicated: - [NAME] stockings on morning and off at HS (nighttime). On 12/26/27 at 2:00 P.M., 12/27/24 at 8:55 A.M., and at 10:05 A.M., the surveyor observed Resident #52 lying in bed, and he/she did not have compression stockings on his/her legs. Review of Resident #52's Medication Administration Record (MAR) dated December 2024, indicated: - Apply TED stockings at 6:00 A.M. and remove in the evening. Staff documented compression stocking were applied and removed daily throughout the month, including 12/26/24 and 12/27/24. During an interview with Certified Nurse Aide (CNA) #2 on 12/27/24 at 8:57 A.M., she said she had worked with Resident #52 for many months and had never known him/her to wear compression stockings. CNA #2 said she had not received instruction from licensed nurses to apply compression stocking. During an interview with Nurse #3 on 12/27/24 at 9:05 A.M., he said Resident #52 did not wear compression stockings and he was unaware that the Resident had a physician's order for TED/compression stockings. During an interview with the Director of Nurses (DON) on 12/27/24 at 10:52 A.M., she said physician's orders for compression stockings should be followed. 41105 2. Resident #17 was admitted to the facility in December 2016 and has diagnoses that include diabetes and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that on the Brief Interview for Mental Status exam Resident #17 scored a 12 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #17 had no behaviors of rejecting care and was dependent on staff for lower body dressing. Review of the current physician orders indicated the following: - Heel protector boots on at all times, may remove for transfers, start date 8/13/24. Review of the most recent Nurse Practitioner progress note, dated 12/11/24, indicated: - Peripheral vascular disease: status post left calcinatory - healed. - Continue protective boots daily. Review of the December 2024 clinical progress notes failed to indicate Resident #17 refused to wear heel protector boots. Review of the Certified Nursing Assistant (CNA) task documentation failed to indicate Resident #17 displayed any behavior of rejecting care in the past 14 days. Review of the current Diabetes care plan included the following intervention: - Diabetic foot care, start date 12/28/16. Review of the current Activities of Daily Living care plan included the following intervention: -Extensive assist with daily bathing, grooming, dressing. Dependent when tired, dated as revised 3/15/21. During an observation and interview on 12/26/24 at 8:43 A.M., the surveyor observed Resident #17 in bed with both heels resting flat on the mattress. Two blue boots were located across the room on top of the Resident's wheelchair. Resident #17 said the boots were supposed to be put on by the staff but had not been. On 12/27/24 at 8:11 A.M., the surveyor observed Resident #17 asleep in bed. A bootie was on Resident #17's right foot and his/her left foot was flat on the mattress, with no heel protector boot on. Another bootie was observed across the room on top of Resident #17's wheelchair. On 12/27/24 at 10:18 A.M., the surveyor observed Resident #17 in bed. Resident #17 wore a bootie on the right foot and his/her left foot was flat on the mattress, with no heel protector boot on. Another bootie was observed across the room on top of Resident #17's wheelchair. A sign posted on the wall behind Resident #17's bed indicated blue multipodus boots must be donned at all time (sic). During an interview and observation on 12/30/24 at 8:23 A.M., Resident #17 was lying in bed, awake. The Resident was not wearing heel protector boots on either foot. Resident #17 said that he/she had not worn a heel protector boot on the left foot while in bed for many months. The Resident said he/she used to wear a boot on the left foot at night, but that the boot was lost, and staff had replaced it with a boot that did not fit. Resident #17 said staff eventually stopped applying the left boot. During an interview with Unit Manager #1 on 12/30/24 at 8:33 A.M., she said she was unaware that Resident #17 had a physician's order for bilateral heel protectors. On 12/30/24 at 8:39 A.M., the surveyor and Unit Manager #1 entered Resident #17's room and observed that Resident #17 was not wearing heel protectors on either foot. Across the room a single heel protector was located on top of a wheelchair. During an interview with CNA #2 on 12/30/24 at approximately 9:00 A.M., she said she was unaware that Resident #17 was supposed to wear heel protectors. CNA #2 said she had not received instruction from licensed nursing staff to apply heel protection to Resident #17's heels. During an interview with the Director of Nurses (DON) on 12/27/24 at 10:52 A.M., she said physician's orders should be followed. 45763 3. Resident #442 was admitted to the facility in November 2024 with diagnoses of cerebral palsy and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #442 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident was cognitively intact. Review of Resident #442's care plans failed to indicate a care plan outlining the level of assistance the Resident needed for eating. Review of Resident #442's Occupational Therapy (OT) initial assessment, dated 12/19/24, indicated that Resident #442 presented with impairments in balance, fine motor coordination, gross motor coordination and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care; the OT initial assessment indicated that Resident #442 required moderate assistance with eating at baseline. Further review of the OT initial assessment indicated that Resident #442 had a bilateral upper extremity tremor, and that the Resident was not able to hold a cup of water in order to sip from a straw, and that the therapist had to hold the cup as the Resident drank from the straw. Review of Resident #442's OT treatment encounter notes, dated 12/19/24, 12/20/24, 12/21,24, 12/22/24, 12/23/24, 12/26/24, 12/27/24, and 12/29/24 indicated the Resident required partial/moderate assistance with eating. On 12/26/24 at 8:20 A.M., the surveyor observed Resident #442 eating breakfast in bed and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself; the Resident was dropping a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/26/24 at 12:14 P.M., the surveyor observed Resident #442 eating lunch in bed and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/27/24 at 8:18 A.M., the surveyor observed Resident #442 eating breakfast in bed, and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/27/24 at 12:19 P.M., the surveyor observed Resident #442 eating lunch in bed, and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself; the Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/30/24 at 8:10 A.M., the surveyor observed Resident #442 eating breakfast in bed, and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself; the Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. During an interview on 12/30/24 at 9:49 A.M., Resident #442 said he/she needs assistance with eating as the tremors have gotten worse over the years and that he/she can't keep his/her food on the spoon. During an interview on 12/30/24 at 9:37 A.M., Nurse #13 said he would expect a care plan to be developed outlining the level of assistance Resident #442 needed for eating. Nurse #13 said Resident #442 required only set-up assistance with eating. During an interview on 12/30/24 at 10:55 A.M., the Occupation Therapist (OT) said that the OTs will assess the level of assistance residents need with ADLs, and that Resident #442 required at a minimum standby assistance to moderate/partial assistance with eating. The OT said that she would expect a staff member to be always in the room during a meal period to provide feeding assistance to the Resident. The OT said that she would expect the level of assistance to be included in a care plan. The OT said the level of assistance was outlined in the goals section of the OT therapy notes but she wasn't sure if nurses or Certified Nursing Aides had access to those records as they were in a different system. The OT said that the therapy department would give verbal reports to nurses regarding the level of assistance a resident needed based on their evaluation. During an interview on 12/30/24 at 11:51 A.M., the Director of Nursing (DON) said that if OT determined that a resident needed assistance with eating that this would be included in a care plan and that she would expect the resident to receive the level of assistance determined by the OT. The DON said she did not believe nursing staff had access to therapy documentation as it was stored in a separate system. 48671 4. Resident #46 was admitted to the facility in October 2019 and has diagnoses that include Cerebral Palsy (condition that affect movement and posture) and history of falling. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that on the Brief Interview for Mental Status exam Resident #46 scored an 11 out of a possible 15, signifying moderately impaired cognition. The MDS further indicated that Resident #46 did not have a behavior of rejecting care. Review of the current care plans for Resident #46 indicated: Focus: ADL (activities of daily living) Self-care deficit related to limited ROM (range of motion) related to Cerebral palsy, dated as initiated 10/9/19. Interventions include: - Continual Supervision in Wheelchair, dated as initiated 7/18/22. - Assist w/ (with) wheelchair transportation, dated as initiated 10/9/19. Focus: At risk for falls due to impaired balance/poor coordination, unsteady gait and potential adverse side effects of meds, limited ROM (range of motion) to BUE (bilateral upper extremities) due to tremors, non-compliant w/ attempting independent ambulation. Unable to use w/c (wheelchair) cushion due to the way Resident positions him/herself in w/c, non-compliant w/ sitting up in chair, dated as initiated 10/17/19. Interventions include: - Reinforce wheelchair safety as needed such as locking brakes, dated as initiated 4/23/20. - Provide assistance to transfer and ambulate as needed, dated as initiated: 4/23/20. Review of the current Kardex (form indicating level of care needs), indicated the following: - Mobility: Assist w/ (with) wheelchair transportation. - Reposition w/ assist (assistance) of 1 or 2 staff as needed, bed and chair. - Transfer w/ assist of 1 or 2 staff as needed. On 12/26/24 at 8:25 A.M., the surveyor observed Resident #46 wheeling him/herself in the hallway almost completely sliding out of the wheelchair. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/26/24 at 8:27 A.M., the surveyor observed Resident #46 using his/her feet to wheel him/herself from the hallway into his/her room. Anti-tippers were observed on the wheelchair. The Resident entered the room, went to the bed, and attempted to [NAME] his/her body forward out of chair, and pulling on the call cord as leverage. The Resident then gave up and sat down in the wheelchair. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/26/24 at 8:29 A.M., the surveyor observed Resident #46 twitching and had spastic movements as he/she slid down in the wheelchair until he/she was almost laying down. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/26/24 at 8:35 A.M., the surveyor observed Resident #46 in the hallway almost completely sliding out of the wheelchair. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/27/24 at 8:27 A.M., the surveyor observed Resident #46 sitting in a wheelchair and propelling around the nursing unit. There were no staff present during the observation. The Resident entered another resident's room and sat in the doorway for a few minutes before exiting the room. The surveyor observed Resident #46 wheeling him/herself out into the hall and was completely sliding out of the wheelchair using his/her feet to propel the wheelchair forward. The Resident wheeled down the hall into his/her own room. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/27/24 at 8:37 A.M., the surveyor observed Resident #46 in the hallway almost completely sliding out of the wheelchair. The Resident was twitching and had spastic movements as he/she slid down in the wheelchair until almost laying down. The Resident continued to propel forward using his/her feet to move the wheelchair forward. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/27/24 at 9:05 A.M., the surveyor observed Resident #46 in the hallway almost completely sliding out of the wheelchair. The Resident was twitching and had spastic movements as he/she slid down in the chair until almost laying down. The Resident wheeled him/herself into the doorway of his/her room and began to stand up by placing both hands on the overbed tray table and pulled and shoved the table into the doorway. The wheelchair was rolling as Resident #46 twisted his/her body and abruptly sat in the wheelchair. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/27/24 at 1:29 P.M., the surveyor observed Resident #46 in the hallway almost completely sliding out of the wheelchair. The Resident was twitching and had spastic movements as his/her body slid down in the chair until almost laying down. The Resident wheeled him/herself into the doorway of his/her room and began to stand up placing both hands on the overbed tray table and began to pull and shove the table into the doorway. Resident #46 grabbed the edge of his/her wheelchair and pulled the chair closer to the overbed table and began to push the table with his/her feet into the doorway. There were no staff present in the hall or at the nurse's station throughout the observation. On 12/30/24 at 7:07 A.M., they surveyor observed Resident #46 wheeling him/herself in the hallway almost completely sliding out of the wheelchair. The Resident was twitching and had spastic movements as he/she slid down into the chair until almost laying down. There were no staff present in the hall or at the nurse's station throughout the observation. During an interview on 12/30/24 at 8:18 A.M., Certified Nursing Assistant (CNA) #4 said Resident #46 does not require supervision when in his wheelchair because he/she likes their privacy. During an interview on 12/30/24 at 8:23 A.M., Nurse #14 said Resident #46 requires continuous supervision when in the wheelchair because he/she slides down and is a fall risk. Nurse #14 said staff must observe the Resident because he/she will move around the unit. Nurse #14 said Resident #46 needs constant reminders to not back into anyone and to sit up because he/she slides down but will not use a cushion on the wheelchair. During an interview on 12/30/24 at 8:35 A.M., Unit Manager #1 said Resident #46 needs supervision due to safety and said the Resident will wander all over the unit in his/her wheelchair. Unit Manager #1 said Resident #46 requires supervision and should not be left alone or unsupervised while sitting in the wheelchair and said staff use the care plan and Kardex (form indicating level of care needed) to know what type of care and supervision is needed. Unit Manager #1 said staff are expected to follow care plan interventions. During an interview on 12/30/24 at 1:38 P.M., the Director of Nursing (DON) said staff should not be leaving Resident #46 unsupervised while in the wheelchair and said it is her expectation that staff provide continual supervision and follow the care plan interventions especially if the Resident is known to slide down in his/her wheelchair. The DON Resident #46 can wheel themselves around the unit but needs staff supervision.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for one Resident (#392) out of a total of 37 sampled residents. Specifically, for Resident #392 the facility failed to ensure nursing clarified a physician's order for ascorbic acid extended release (ER) oral capsule. In addition, from 12/15/24 through 12/26/24, nursing staff documented they administered the medication 25 times. Findings include: Review of the facility policy titled Administering Medications, dated as revised 5/16/24, indicated that medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #392 was admitted to the facility in December 2024 with diagnoses including diabetes, chronic pain, and colitis. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/21/24, indicated that Resident #392 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. On 12/27/24 at 10:18 A.M., the surveyor observed Nurse #6 prepare to administer medications to Resident #392. Nurse #6 reviewed Resident #392's orders and said she has never seen Ascorbic Acid ER Oral Capsule 500 milligrams as a form of the medication. Nurse #6 said the pharmacy had not delivered the medication and she would have to review the order. Review of Resident #392's physician's order, dated 12/14/24, indicated: - Ascorbic Acid ER Oral Capsule 500 milligrams, give one capsule by mouth two times a day for wound healing. Review of Resident #392's Medication Administration Record, dated December 2024, indicated nursing administered Ascorbic Acid ER Oral Capsule as ordered between 12/15/24 and 12/26/24 for 25 administrations. During an interview on 12/30/24 at 10:05 A.M., Unit Manager #2 said that nursing should have clarified the ascorbic acid ER order to the form on hand and with the physician. Unit Manager #2 said that the facility does not stock ascorbic acid ER. During an interview on 12/30/24 at 12:18 P.M., the Director of Nursing said nursing should have clarified the order for ascorbic acid ER to the form on hand and with the physician.

Based on observation, interview and record review the facility failed to provide assistance with activities of daily living (ADL's) for one Resident (#442) out of a total sample of 37 residents. Specifically, for Resident #442 the facility failed to ensure the Resident received necessary services to maintain good nutrition. Findings Include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, but was not limited to, the following: - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: - Dining (meals and snacks). - The resident's response to interventions will be monitored, evaluated and revised as appropriate. Resident #442 was admitted to the facility in November 2024 with diagnoses of cerebral palsy and malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #442 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating the Resident was cognitively intact. Review of Resident #442's care plans failed to indicate a care plan outlining the level of assistance the Resident needed for eating. Review of Resident #442's Occupational Therapy (OT) initial assessment, dated 12/19/24, indicated the Resident presented with impairments in balance, fine motor coordination, gross motor coordination and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care. The OT initial assessment indicated that Resident #442 required moderate assistance with eating at baseline. Further review of the OT initial assessment indicated that Resident #442 had a bilateral upper extremity tremor and was unable to hold a cup of water in order to sip from a straw. The OT assessment indicated the therapist had to hold the cup as the Resident drank from the straw. Review of Resident #442's OT treatment encounter notes, dated 12/19/24, 12/20/24, 12/21,24, 12/22/24, 12/23/24, 12/26/24, 12/27/24, and 12/29/24 indicated the Resident required partial/moderate assistance with eating. On 12/26/24 at 8:20 A.M., the surveyor observed Resident #442 eating breakfast in bed and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/26/24 at 12:14 P.M., the surveyor observed Resident #442 eating lunch in bed and there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/27/24 at 8:18 A.M., the surveyor observed Resident #442 eating breakfast in bed, there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/27/24 at 12:19 P.M., the surveyor observed Resident #442 eating lunch in bed, there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. On 12/30/24 at 8:10 A.M., the surveyor observed Resident #442 eating lunch in bed, there were no staff members in the room or within eyesight of the Resident. The surveyor observed that Resident #442's hands were trembling, and that the Resident was having difficulty feeding him/herself. The Resident dropped a significant portion of his/her food on his/her chest where he/she could not retrieve it. During an interview on 12/30/24 at 9:49 A.M., Resident #442 said he/she needs assistance with eating as the tremors have gotten worse over the years and that he/she can't keep his/her food on the spoon. During an interview on 12/30/24 at 9:37 A.M., Nurse #13 said the staff know the level of assistance a resident needs based on the verbal nurse report, and that if there was any uncertainty regarding the level of assistance a resident needed with a specific ADL task that nursing would clarify with the rehabilitation department. Nurse #13 said he would expect a care plan to be developed outlining the level of assistance a resident needed for eating. During an interview on 12/30/24 at 10:55 A.M., the Occupation Therapist (OT) said that the OTs will assess the level of assistance residents need with ADLs and that Resident #442 requires at a minimum standby assistance to moderate/partial assistance with eating. The OT said that she would expect a staff member to be always in the room during a meal period to provide feeding assistance to the Resident. The OT said that she would expect the level of assistance to be included in a care plan. The OT said the level of assistance was outlined in the goals section of the OT therapy notes but she wasn't sure if nurses or Certified Nursing Aides had access to those records as they were in a different software system. The OT said that the therapy department would give verbal report to nurses regarding the level of assistance a resident needed based on their evaluation. During an interview on 12/30/24 at 11:51 A.M., the Director of Nursing (DON) said that if OT determined that a resident needed assistance with eating that this would be included in a care plan and that she would expect the resident to receive the level of assistance determined by the OT. The DON said she did not believe nursing staff had access to therapy documentation as it was stored in a separate software system.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#29) out of a total sample of 37 residents. Specially, the facility failed to obtain wound care orders for five days after Resident #29's wound vac (negative pressure wound vacuum, which is a medical device that uses suction to help a wound heal by gently pulling fluid out of it and keeping the edges of the wound together) was placed on hold because the wound was worsening. Finding include: Review of the facility policy titled Medication and Treatment Order, dated as revised July 2016, indicated that orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. Resident #29 was admitted to the facility in November 2024 with diagnoses including osteomyelitis of the right ankle and foot, diabetes, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/28/24, indicated that Resident #29 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. This MDS indicated Resident #29 had one stage 3 pressure ulcer, and a surgical wound. This MDS indicated Resident #39 received pressure ulcer/ injury care, surgical wound care, application of nonsurgical dressings, and application of dressing to feet. On 12/26/24 at 8:58 A.M., the surveyor observed Resident #29's right foot. The right foot was wrapped in undated gauze. Resident #29 said that nursing is applying Santyl (topical prescription ointment that is used for wound care, helping to break up and remove dead skin and tissue) daily until the wound vac goes back on Saturday 12/28/24. On 12/27/24 at 11:04 A.M., the surveyor observed Resident #29's right foot. The right root was wrapped in gauze and dated 12/26/24. Review of Resident #29's plan of care related to skin break down right heel ulcer, dated 11/21/24, indicated: - Administer treatment per physician's order. - Wound vac treatment as ordered. Review of Resident #29's physician's order, dated 11/21/24, indicated: - Wound Vac. right heel, every shift for right heel ulcer. Monitor Settings every shift - Keep at 125 mmHg. Review of Resident #29's podiatry note, dated 12/24/24, indicated: - Resident presents to clinic for urgent evaluation given worsening appearance of the wound. Saw infectious disease earlier today. Resident is at rehabilitation and reports wound VAC was stopped on Monday given maceration. Requested urgent evaluation by podiatry given worsening appearance of wound with malodor. Has been applying Santyl daily since the wound VAC was stopped. - Clinical findings discussed with the resident. Gentle excisional debridement to the level of the subcutaneous tissues using a curette. Wound was cleansed with betadine dressing applied. Padding applied to the hallux lesion. Will continue with daily Santyl at home to reduce fibrotic slough, can reapply wound VAC likely Saturday. Review of Resident #29's nursing progress note, dated 12/24/24, indicated: - Wound vac to be restarted on Saturday 12/28/24. Review of Resident #29's nursing progress note, dated 12/25/24, indicated: - Right heel dressing changed per order. Review of Resident #29's Orders - Administration Note, dated 12/28/24 at 2:33 P.M., indicated: - Patient reports he/she hasn't had a wound vac in over a week. No wound vac in place. Review of Resident #29's Physician's orders and Treatment Administration Record (TAR), dated December 2024, failed to included orders for Santyl between 12/24/24 through 12/28/24. During an interview on 12/30/24 at 8:54 A.M., Resident #29 said that his/her wound vac was changed yesterday, 12/29/24. Resident #29 said nursing did not complete dressing changes on 12/27/24 or 12/28/24. Resident #29 said nobody knew what they were supposed to do with the wound. Resident #29 said there were a bunch of nurses who said there was no order, and nobody would do anything about it. During an interview on 12/30/24 at 9:57 A.M., Unit Manager #2 said Resident #29 knows his/her medications, orders, and plan of care. Unit Manager #2 reviewed Resident #29's medical record, physician's orders, and podiatry note. Unit Manager #2 said there were no orders for the use of Santyl while the wound vac was on hold and said there were no dressing orders at all while the wound vac was placed on hold but there should have been. Unit Manager #2 said that use of Santyl requires a physician's order. During an interview on 12/30/24 at 12:29 P.M., the Director of Nursing said nursing should have obtained orders for treatments for Resident #29's wound while the wound vac was on off and on hold. On 12/30/24 and again on 1/2/25 the surveyor called and requested interviews from Nurse #7, Nurse #8, Nurse #9, and Nurse #10 all of whom were assigned to care for Resident #29 between 12/24/24 and 12/29/24. Nurse #7, Nurse #8, Nurse #9, and Nurse #10 did not return the surveyor's call.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two Residents (#441 and #119) out of a total of 37 sampled Residents. Specifically: 1. For Resident #441, the facility failed to place an order for treatment or monitoring for a known pressure injury on admission. 2. For Resident #119, the facility failed to ensure nursing consistently implemented physician's orders for air mattress settings. Findings include: Review of the facility policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised March 2014, indicated, but was not limited to, the following: - The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. - The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatments, etc. - During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or non-healing wounds. 1. Resident #441 was admitted to the facility in December 2024 with a diagnosis of Alzheimer's disease. There was no Minimum Data Set (MDS) assessment available for Resident #441 at the time of survey. Review of Resident #441's hospital discharge paperwork, dated 12/22/24, indicated that the Resident had a DTPI (deep tissue pressure injury) on his/her coccyx. Review of Resident #441's Norton Plus Skin Risk Assessment, dated 12/23/24, indicated the Resident was at high risk for developing pressure injuries. Review of Resident #441's clinical admission progress note, dated 12/23/24, indicated the Resident had a pressure injury on his/her coccyx and that the wound was present on admission. Review of Resident #441's active physician orders failed to indicate an order to monitor or treat Resident #441's coccyx wound. During an interview on 12/26/24 at 10:27 A.M., Nurse #11 said that Resident #441 did not have any orders to monitor or treat wounds, preventive or otherwise, because the Resident's skin was intact. During an interview on 12/26/24 at 2:03 P.M., Certified Nursing Aide (CNA) #2 said that she had been unable to visualize Resident #441's coccyx as the Resident currently had a dressing covering his/her coccyx. During an interview and observation on 12/26/24 at 2:28 P.M., two surveyors accompanied Nurse #11 to observe Resident #441's coccyx. A surveyor and Nurse #11 observed that Resident #441 had an undated dressing covering his/her coccyx; Nurse #11 said that he did not know that the Resident had a dressing in place. A surveyor and Nurse #11 observed that Resident #441 had a wound on his/her coccyx. Nurse #11 said that the wound was a pressure injury and measured three centimeters (cm.) by two cm. Nurse #11 said that he had been taking care of the Resident yesterday and today but was not aware that the Resident had a pressure injury. During an interview on 12/26/24 at 2:39 P.M., Unit Manager #4 said that Resident #441 was admitted to the facility with a wound on his/her coccyx. Unit Manager #4 said that the Resident did not have a wound treatment order from the hospital. Unit Manager #4 said that the facility process for residents admitted with a wound was that nursing would initiate an order for treatment and monitoring of the wound. Unit Manager #4 said a treatment order for Resident #441's wound should have been initiated on admission but wasn't. During an interview on 12/30/24 at 9:15 A.M., the physician said she would expect the Unit Manager to look at the wound of a newly admitted resident to ensure that a treatment was available. The physician said that she would expect an order to be placed for the treatment and monitoring of any pressure injury, including a DTPI. During a follow-up interview on 12/30/24 at 10:06 A.M., the physician said she agreed with nursing's previous assessments of the wound, that the wound had not changed since admission based on the nurse description of the wound and that she would recommend a treatment of Santyl (an ointment used to remove damaged tissue from skin ulcers) and dry protective dressing. The physician said she would have expected an air mattress to have been in place since admission. On 12/26/24 at 8:19 A.M., the Surveyor observed Resident #441 in bed, and the Resident was not on an air mattress. Further review of Resident #441's orders indicated that an order for an air mattress was initiated three days after the Resident's admission and after the surveyor had brought the concern to the attention of the facility. During an interview on 12/30/24 at 11:51 A.M. the Director of Nursing (DON) said nurses should not apply treatments without an order and that dressings should be dated. The DON said that Resident #441 should have had an order for treatment and monitoring of his/her DTPI on admission. 44095 2. Review of the facility policy, Support Surface Guidelines, dated as revised September 2013, indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. - Preparation 1. Review the resident's care plan to assess for any special needs of the resident. - General Guidelines 3. Support surfaces are modifiable. Individual resident needs differ. - Interventions/Care Strategies 6. Monitor for other pressure ulcer risk factors and provide interventions as indicated. Resident #119 was admitted to the facility in February 2024 with diagnoses including dysphagia and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that Resident #119 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS indicated Resident #119 had one unstageable - deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.) Review of Resident #119's plan of care related to alteration in skin integrity, dated 4/22/24, indicated: - Air Mattress - Setting at 150 lbs. Review of Resident #119's physician's order, dated 4/22/24, indicated: - Air mattress to bed check placement and function, Keep Settings at 150 pounds every shift. Review of Resident #119's Norton Plus Skin Risk assessment dated [DATE], indicated he/she was at high risk for pressure ulcers as evidenced by a score of 8. Review of Resident #119's weights in the electronic health record, dated 12/12/24, indicated Resident #119's most recent weight was 164.4 pounds. On 12/26/24 at 8:31 A.M., 12/26/24 at 11:25 A.M., 12/26/24 at 4:07 P.M., and 12/26/24 at 5:09 P.M., the surveyor observed Resident #119 in his/her bed with the air mattress set to 200 pounds. On 12/27/24 at 6:39 A.M., 12/27/24 at 8:01 A.M., 12/27/24 at 12:28 P.M., and 12/27/24 at 3:05 P.M., the surveyor observed Resident #119 in his/her bed with the air mattress set to 200 pounds. On 12/30/24 at 6:36 A.M. and 12/30/24 at 10:58 A.M., the surveyor observed Resident #119 in his/her bed with the air mattress set to 200 pounds. Review of Resident #119's physician's order, dated 10/30/24, indicated: - Consults: Wound Consult evaluation and treat as needed. Review of Resident #119's skin note, dated 12/19/24, indicated: - Resident seen by wound doctor for right buttock pressure. length 0 cm, width 0 cm, depth 0 cm. Status: resolved. Treatment: cleanse w/normal saline apply Triad, leave open to air, every shift and as needed. Review of Resident #119's wound care specialists electronic health record follow up short, dated 12/19/24, indicated: First evaluated on 10/31/24 Context: Moisture Associated Skin Damage (MASD) Associated signs and symptoms: Pain. 10/31/24 - Patient is an [AGE] year old for whom a consult was placed for wounds of the Bilateral Buttocks (BL). BL Buttocks consistent with MASD with denuded skin R greater than (>) L. Will start treatment plan today. 11/14/24 - MASD stable overall now L>R. Will update treatment plan today. 11/27/24 - R buttock now consistent with Deep Tissue Pressure Injury (DTPI). Will update treatment plan today. 12/5/24 - R Buttock DTPI is significantly smaller. Will continue tx. 12/12/24 - R buttock DTPI is slightly smaller. Continue tx. 12/19/24 - DTPI has epithelialized. Will transfer care to Nursing staff. Wound: 3 Location: Right, Buttock Primary Etiology: Pressure Stage/Severity: Deep tissue pressure injury (DTPI) Wound Status: Resolved Odor Post Cleansing: None Size: 0 cm x 0 cm x 0 cm. Calculated area is 0 sq cm. Wound Edges: Attached Periwound: Erythema (red), Moist Wound Base: 100% epithelial Exudate: None amount of None Wound Pain at Rest: 0 Wound # 3 Right, Buttock Pressure Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Triad to BL Buttocks. 3. Secure with Leave open to air. 4. Change Every shift, PRN. Review of Resident #119's the N Adv - Skin Check, dated 12/21/24, indicated: - Skin Issues Note: Right buttock pressure. Review of Resident #119's physician's order, dated 12/21/24, indicated: - Cleanse right buttock deep pressure injury with normal saline, apply Triad, leave open to air, every shift for wound and as needed. During an interview on 12/30/24 at 10:55 A.M., Certified Nurse Assistant (CNA) #1 said that Resident #119 has open areas on his/her buttocks. CNA #1 said that she doesn't adjust air mattress settings. During an interview on 12/30/24 at 10:23 A.M., Nurse #2 said that air mattresses are set according to the physician's order. On 12/30/24 at 11:00 A.M., the surveyor observed Resident #119's buttocks with CNA #1, Nurse #2, and the Assistant Director of Nursing (ADON). The ADON said Resident #119's buttocks were red, macerated, excoriated and open. There were 2 shallow open areas of epithelized tissue on the right side of the coccyx, one on the coccyx and one on the left side of the coccyx. The surrounding tissue was red and discolored. During an interview on 12/30/24 at 12:24 P.M., the Director of Nursing said Resident #119's air mattress is ordered for his/her deep tissue injury and said that nursing should set the air mattress according to the physician's order.

Based on observations, record review, policy review and interviews, the facility failed to 1) prevent a fall resulting in a humeral (arm bone) fracture for one Resident (#19) and 2) ensure bed and chair alarms were in place for two Residents (#23 and #47) out of a total sample of 32 residents. Findings include: 1.) Review of the facility policy titled 'Falls and Fall Risk, Managing', dated as revised March 2018, indicated the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce specific risk factor(s) of falls for each resident at risk or with a history of falls. Resident #19 was admitted to the facility in May 2014 with diagnoses including hemiplegia (one sided paralysis) after a stroke, abnormalities of gait, abnormal posture and dementia. Review of Resident #19's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #19 was dependent on staff for all transfers. During an interview on 1/8/24 at 7:44 A.M., Resident #19 was observed sitting in his/her wheelchair and was wearing a sling to his/her left arm. Resident #19 said he/she had sustained a recent fall, which resulted in a broken arm. Resident #19 said the fall occurred when he/she was transferring out of bed with the assistance of a CNA (Certified Nursing Assistant). Resident #19 said the CNA stood him/her up to pivot transfer into the wheelchair and did not use the mechanical lift machine to complete the transfer. Review of the nursing note dated 12/25/23 indicated the following: Resident alert with periods of forgetfulness. S/P fall @ 6 am with no apparent injuries. Denies pain and no discomfort on shift. This writer observed the Resident sitting on the floor next to the bed and in front of the scooter. The staff notified this writer, Resident lost (his/her) balance during transfer from bed to chair and the staff lowered patient to the floor. Resident stated that during transfer from bed to chair, I lost my balance and the staff lowered me to the floor. Full assessment done while the Resident was seated on the floor. No apparent injuries observed. Resident denies pain. VSS (vital signs stable). + ROM (range of motion) to BUE (both upper extremities) and BLE (both lower extremities). Patient assisted off the floor and into (his/her) scooter with no discomfort noted. Resident denied any discomfort during the transfer from the floor to the chair. Son and NP notified. Order for x-ray to be done on 12/26/23. safety maintained. An incident report dated 12/25/23 including a witness statement from the CNA (CNA #7) completing the transfer at the time of the fall indicated the following: I used to transfer with 1 assist about a year ago. the patient didn't say (he/she) used a hoyer (mechanical lift) - used gait belt for transfer, I had no idea (he/she) was a hoyer. As I transferred (him/her) (he/she) lost (his/her) balance and was lowered to the floor. I did not notice anything that would have cause (sic) injury and gait belt was used to transfer (him/her) back to the chair. Review of the orthopedic note dated 12/26/23 indicated Resident #19 was diagnosed with a minimally displaced acute left proximal humeral fracture. Review of Resident #19's fall care plan last revised 10/20/23, indicated the following: -Provide assistance to transfer mechanical lift with 2 assists. This intervention was initiated on 10/13/23, over two months before the Resident's fall. Review of Resident #19's activity of daily living care plan last revised 5/24/23, indicated the following: -Mechanical lift for transfers. This intervention was initiated on 10/13/23, over two months before the Resident's fall. Review of Resident #19's Kardex (a form indicating the level of assistance a resident requires) indicated the following: -Mechanical lift for transfers. -Assist of 2 staff for all transfers mechanical lift large pad. Review of the nursing summary dated 9/23/23 indicated Resident #19 required the physical assistance of two staff members with the use of a mechanical lift for all transfers. During an interview on 1/9/24 at 8:08 A.M., CNA #4 said all staff are expected to read the Kardex for each resident to know the level of care the resident requires. CNA #4 said Resident #19 had been changed to a mechanical lift transfer but the staff transfer the Resident based on how he/she is feeling that day. CNA #4 said the staff should ultimately follow the Kardex and plan of care to ensure safety even if a resident were to ask for a different way of transferring. During an interview on 1/9/24 at 10:47 A.M., Nurse #5 said Resident #19 had been a mechanical lift transfer for at least 6 months and said a mechanical lift should have been used at the time of the fall and was not. During an interview on 1/9/24 at 10:51 A.M., Unit Manager #3 said the fall occurred because the staff attempted to transfer Resident #19 without the use of a mechanical lift. During an interview on 1/9/24 at 1:32 P.M., the Director of Nursing and Regional Nurse #1 said the fall occurred as a result of the staff not using the proper transfer technique. The Director of Nursing said a mechanical lift should have been used to transfer Resident #19 and it was not. 36431 2.) Review of the facility's policy titled 'Safety; Interventions and Devices, with a revision date of 9/14/2012 indicated: -Policy: Safety devices will be used for residents who are at risk for falls, as determined to be necessary or appropriate by the charge nurse, with input from the interdisciplinary team. Safety devices include but are not limited to bed alarms, body alarms, low beds, mats on the floor next to the bed, and helmets. -Process: 6.1 A physician order for the alarm device will be obtained and the order will be listed on the treatment administration record (TAR). 6.3 The nurse caring for the resident will check the alarm placement and function each shift and document in the TAR. 2a.) For Resident #23 the facility failed to implement the chair alarm in accordance with the physician's orders. Resident #23 was admitted to the facility in October 2019 and has diagnoses that include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Alzheimer's disease. Review of Resident #23's Minimum Data Set assessment, dated 12/21/23, indicated Resident #23 scored a 2 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment and requires substantial assistance from staff for daily care. Further, the MDS indicated bed and chair alarms are used daily. Review of Resident #23's medical record indicated the following: -A care plan: Actual falls due to medication side effects-psychotropic meds, unsteady gait, dated as revised 11/6/23. Interventions included chair alarm, dated 10/11/21. -A physician's order, dated 6/22/21, chair alarm, check placement and function every shift. The surveyors made the following observations: -On 1/08/24 at 12:17 P.M., Resident #23 was sitting in a wheelchair in the activity room, no chair alarm was on the wheelchair. -On 1/08/24 at 4:27 P.M., Resident #23 was sitting in a wheelchair in the activity, no chair alarm was on the wheelchair. -On 1/09/24 at 8:59 A.M., Resident #23 was sitting in a wheelchair in the activity room. A wire was wrapped around the chair and no chair alarm box was on the chair. Resident #23 attempted to stand and then sat back down. -On 1/11/24 at 8:09 A.M., Resident #23 was sitting in a wheelchair in the activity room. The chair was not equipped with a chair alarm. During an interview on 1/11/24 at 8:17 A.M. CNA #5 said Resident #23 is a fall risk and uses a bed and chair alarm. The surveyors and CNA #5 observed Resident #23 in the activity room and CNA #5 said the chair alarm was not on the chair and went to look for it in Resident #23's room. During an interview on 01/11/24 at 8:28 A.M., Unit Manager #1 said the chair alarm should be always in use when Resident #23 is sitting in his/her chair. 2b.) For Resident #47 the facility failed to implement the bed and chair alarm in accordance with the medical plan of care. Resident #47 was admitted to the facility in November of 2023 and has diagnoses that include but not limited to spinal stenosis, covid-19, toxic encephalopathy, visual loss both eyes, dysphagia, and chronic kidney disease. Review of the Minimum Data Set assessment, dated 11/24/23, indicated Resident #47 scored a 4 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment and is dependent on staff for bathing, toileting, and dressing. Further, the MDS indicated a bed and chair alarm are used daily. Review of Resident #47's medical record indicated the following: -A physician's order dated 11/17/23, bed alarm check placement and function every shift -A physician's order dated 11/17/23, chair alarm check placement and function every shift. -A care plan dated 11/22/23, at risk for falls due to history of falls, sensory deficit. Interventions dated 11/22/23 bed alarm, chair alarm. During the survey the following observations were made: -On 1/08/24 at 11:38 A.M., Resident #47 was in the activity room in a wheelchair with no chair alarm. -On 1/08/24 at 4:30 P.M., Resident # 47 was in bed with no bed alarm in place. -On 1/09/24 at 11:00 A.M., Resident was in the activity room in a wheelchair with no chair alarm. -On 1/11/24 at 8:52 A.M., Resident #47 was being pushed in a wheelchair by CNA #1 to the activity room. The wheelchair did not have a chair alarm. During an interview on 1/11/24 at 8: 55 A.M., CNA #1 said Resident #47 will try to get out of bed on his/her own and is at risk of falling. CNA #1 said Resident #47 uses a bed alarm and said she does not use a chair alarm. CNA #1 said she was not aware of the need for a chair alarm. During an interview on 1/11/24 at 9:01 A.M., Nurse #1 said Resident #47 does not spend too much time out of bed and uses a bed alarm. Nurse #1 said if there is an order for a chair alarm it should be in use.

Based on observation, record review, policy review, and interview, the facility failed to 1. assess and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . prevent the deconditioning of pressure ulcers for 2 Residents, (#17, #82) out of a total sample of 25 residents. Review of the facility policy titled Prevention of Pressure Injuries, revised 2020, indicated the following: * Assess the resident on admission for existing pressure injury risk factors and repeat weekly and upon any changes in condition. * Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. * Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) * Reposition resident as indicated on the care plan. Monitoring * Evaluate, report, and document potential changes in the skin. * Review the interventions and strategies for effectiveness on an ongoing basis. Findings include: 1. Resident #94 was admitted in 8/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], section G, indicates that Resident #94 is an extensive assist for toileting and locomotion and is dependent on staff for personal hygiene. Further review of the MDS indicates that Resident #94 is severely cognitively impaired. Review of the current care plans indicates the following: Focus: At risk for alteration in skin integrity related to impaired mobility and incontinence (initiated 8/24/2016) Goal: Skin will remain intact, free from [CONDITION(S)], breakdown, excoriation or bruising until next review (initiated 8/24/2016) Interventions: Provide preventative skin care routinely and as needed (initiated 8/24/2016) Focus: Urinary incontinence related to cognitive decline of Lewy Body dementia (initiated 8/24/2016) Goal: Will be maintained in as clean and dry a dignified state as possible (initiated 5/29/2017) Intervention: Report changes in skin integrity found during daily care (initiated 8/24/2016) Review of the Norton Plus Skin Risk Assessment, dated 2/15/2019, indicates Resident #94 is at high risk for skin breakdown. Review of the progress notes indicated that, on 5/18/2021, a DTI (deep tissue injury) was discovered on the coccyx of Resident #94. Review of the Pressure Ulcer Record, dated 5/18/2021, indicated that Resident #94 obtained a facility acquired pressure ulcer on his/her coccyx. The pressure ulcer measured 7 centimeters by 7 centimeters and was deemed unstageable. Review of the Wound Physician's Initial Wound Evaluation and Management Summary, dated 5/19/2021, indicated that Resident #94's coccyx unstageable pressure wound measured at 5 centimeters squared with 80% black necrotic (dead) tissue and 20% granulation tissue. The wound Medical Doctor (MD) indicated that the duration of the wound had been greater than 14 days. Review of the Treatment Administration Record (TAR) indicated that weekly skin observations were done on 5/1/2021, 5/9/2021, and 5/16/2021 and all of the skin checks were marked with the number 1, which meant there had been a previously identified wound, but did not specify what type of wound existed. Review of the Physician orders, dated 5/1/2021 - 5/31/2021, indicated the following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] * Santyl Ointment to coccyx (initiated 5/19/2021) * Air Mattress (initiated 5/19/2021) * Check placement of coccyx dressing every shift (initiated 5/20/2021) * Check placement of coccyx dressing ( initiated 5/18/2021) During an interview on 6/14/2021 at 8:19 A.M., Unit Manager #1 said that skin checks are completed weekly by nursing and that she should be notified of a pressure ulcer as soon as one is identified. Unit Manager #1 said she believes she was notified of the wound on Monday 5/14/2021, but that she would have to check. During an interview with the Wound Doctor on 9/12/2021 at 9:12 A.M., he said that he would not expect a wound like that to occur within one day and that staff did not mention any wounds to him prior to 5/19/2021 on Resident #94. Review of the Physician's orders do not indicate that any coccyx treatment was put in place prior to 5/18/2021 despite three weekly skin checks being completed with observations of a previous wound and a coccyx wound duration of greater than 14 days, as indicated in the Initial Wound Evaluation and Management Summary. 2. For Resident #17, the facility failed to identify and address existing skin conditions upon admission. Subsequently, Resident #17's wounds worsened. Resident #17 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17 most recent Minimum Data Set Assessment 3/29/21 indicated that he/she requires assistance with bathing, dressing and transferring and is moderately cognitively impaired. On 6/10/21 at 8:15 A.M., the surveyor observed Resident #17 in bed on an air mattress with his/her heels flat on the bed. On 6/11/21 at 8:00 A.M., the surveyor observed Resident #17 in bed. Resident #17's calves were resting on top of a pillow and his/her heels were extended over the pillow lying flat on the bed. Review of Resident #17's Initial Nursing Assessment, dated 3/23/21 indicated that he/she was at high risk for developing pressure ulcers and was admitted to the facility with the following skin issues: Coccyx opened superficial area DTI (deep tissue injury) left heel Left hip 2 incisions Left and Right hip back opened areas Review of Resident #17's care plans effective 3/24/21 indicated the following: Focus: At Risk for alteration in skin integrity related to impaired mobility, dated as initiated 3/24/21: Goal: Will decrease/minimize skin breakdown risks Interventions: Barrier cream to perianal area/buttocks as needed. Diet and supplements per physician order. Encourage and assist to consume fluids as needed. Observe skin conditions and ADL care daily, report abnormalities. Obtain labs as ordered and report results to physician. Pressure redistributing device on bed/chair pressure relieving mattress. Provide preventative skin care routinely and PRN (as needed). Focus: Actual Skin Breakdown related to _________ (specify location and type) (This was left blank) Goal: Will show continued signs of healing. Interventions: Administer treatment per physician orders. The care plans failed to identify Resident #17's actual areas of skin break down. The care plans failed to include interventions to offload Resident #17's heels and/or reposition him/her. Review of Resident #17's physician's orders indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 7:00 A.M.-3:00P.M: 3/25/21 Night shift: 3/26/21 Night shift: 3/28/21 Day shift: 3/29/21 Review of Resident #17's Weekly Skin Check dated 3/30/21 indicated that it was not completed. Review of Physician #1's note dated 3/23/21 indicated that she had requested the Wound Physician assess Resident #17. Review of the Wound Physician's initial evaluation of Resident #17 dated 3/25/21 indicated that the Wound Physician did not assess Resident #17's left heel or coccyx area. Review of the Nurse Practitioner's (NP #1) note for Resident #17 dated 3/25/21 indicated the following: Resident does have a significant deep tissue injury notable on the posterior (back) aspect of the left heel this is offloaded on a pillow. The note did not mention the superficial area on Resident #17's coccyx. Review of the NP #1's note dated 3/29/21 indicated the following: Resident is being seen by the wound specialist regarding a right ischial (lower back) wound as well as his/her left hip lateral ulcerative area that granulated in nicely. I do not see any specific notations about the left heel deep tissue injury. Resident #17 continues to have a darkened area measuring at least an inch and a half circumference on his/her left heel that is being treated primarily keeping the heel offloaded from the bed. The note did not mention the superficial area on Resident #17's coccyx. Review of the Wound Physician's note dated 3/31/21 indicated the following: Wound MD visit 3/31/21: Stage III Left Heel/Sacral ulcer *Unstageable DTI of the left posterior heel *Etiology: Pressure *Wound Size: 4 X 4 X 0.1 CM (Centimeters) *Surface area: 16 cm *Exudate: Moderate Serious (drainage) *Necrotic Tissue (dead tissue): 80% *Slough (dead tissue falling off): 20% Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] gel apply once daily for 30 days Sanytl apply once daily for 30 days. ABD (abdominal) pad non sterile apply once daily for 30 days, gauze roll conforming non-sterile stretch apply once daily for 30 days. Review of Resident #17's Treatment Administration Record dated April 2021 indicated that the above recommendations were not implemented until 4/2/21; 3 days after the wound physician assessed Resident #17. Additional review of the Wound Physician's note dated 3/31/21 also indicated: Stage 3 Pressure wound of the upper sacrum *Etiology: Pressure *Wound Size: 1 X 0.5 X 1 cm *Surface Area: .50 cm *Exudate: Moderate Serous *Slough: 50% *Granulation Tissue: 50% *The wound was debrided. (A bedside surgical intervention to clean the wound) During an interview with Physician #1 on 6/11/21 10:52 A.M., she said that she recalled Resident #17 having a DTI upon admission but not an area on his/her coccyx or sacrum. Physician #1 said that when she requests a wound consultation, her expectation is that all of the resident wounds would be assessed. Physician #1 said that she was not aware that Resident #17 had additional wounds that were not assessed by the Wound Physician on their initial visit. During an interview with Unit Manager #3 on 6/11/21 at 11:00 A.M., she said that when a consult to the wound physician takes place, it is up to the nursing department to inform the Wound Physician of which wounds he should be examining. Unit Manager #3 was unable to recall any specifics regarding Resident #17. During an interview with the Wound Physician on 6/15/21 on 9:21 A.M., he said that when he visits a resident, he is informed by the nursing staff on which wounds he should be assessing. 3. For Resident #82, the facility failed to implement interventions to prevent the deconditioning of a pressure ulcer. Findings include: Resident #82 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82 scored a 10 out of a possible 15 on the Brief Interview for Mental Status, indicating moderate impaired cognition. Resident #82 required assistance with bed mobility, dressing, hygiene, toileting, and bathing. Resident #82 was at risk for developing pressure ulcers. Review of Resident #82's Resident Evaluation dated 5/10/21 indicated the following: -Resident #82 was chair bound with very limited mobility, the Resident required staff assistance to make significant changes in extremity position. -Norton score of 13, indicating moderate risk for skin breakdown. -Resident #82's heels were boggy. Review of Resident #82's nursing progress note dated 6/6/21 indicated left heel open blister 3.5 cm (centimeter) x 3 cm moderate serous drainage, will follow with physician on 6/7/21. (The progress note was inaccurate, Resident #82 had a wound to his/her right heel). Review of Resident #82's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's physician's orders indicated the following: -An order dated 6/9/21 for heel protective booties as tolerated. -An order dated 6/6/21 for right heel normal saline wash and dry protective dressing daily for wound. -An order dated 6/9/21 for right heel normal saline wash and calcium alginate and dry protective dressing daily for wound. Review of Resident #82's skin integrity care plan, initiated 5/20/21, indicated the following interventions: -Pressure redistributing device on bed/chair (specify) dated 5/20/21 -Provided preventative skin care routinely and as needed dated 5/20/21. On 6/10/21 at 9:52 A.M., the surveyor observed Resident #82 in bed, without his/her heels offloaded, and his/her heel protector sitting on a commode in his/her room. Resident #82 said he/she does not always wear his/her heel protectors. On 6/14/21 at 8:09 A.M., the surveyor observed Resident #82 in bed, without his/her heels offloaded, and his/her heel protector sitting on a commode in his/her room. Review of Resident #82's medical record failed to indicate he/she had refused his/her heel protector. Review of Resident #82's Activity of Daily Living self-care deficit care plan, initiated 5/20/21, failed to indicate interventions for prevention of skin breakdown. Review of Resident #82's Pressure Injury Record dated 6/14/21 indicated the following: -Site location: right heel -Date of origin: 6/10/21 -The only wound measurements were recorded on 6/14/21: 6.3 cm x 5 cm. -Slough (yellow or gray necrotic tissue) in the wound bed. -Positioning device: Heel protector. During an interview on 6/14/21 at 2:56 P.M., UM #3 said the progress note written on 6/6/21 was inaccurate and Resident #82 did not have a wound to his/her left heel, the wound had developed on his/her right heel on 6/6/21. She said the wound is now larger and the wound bed is now covered with slough.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was protected from abuse, when on 12/18/19, Certified Nurse Aide (CNA) #1 can be seen and heard on surveillance video footage to physically and verbally abuse Resident #1 during care. Findings include: During an interview on 12/23/19 at 11:00 [NAME]M., Family Member #1 said she set up a hidden camera in Resident #1's bedroom due to concerns with quality of care. FM #1 said she reviewed the video footage from 12/18/19 the following morning (12/19/19) and said after she saw a staff member (later identified as CNA #1) abuse Resident #1, she went to the Facility to discharge Resident #1 and report the abuse. Review of Resident #1 medical record indicated he/she was admitted to the Facility for short term Respite Care, [DIAGNOSES REDACTED].#1 was usually very aggressive and provided the facility with information related to Resident #1's known triggers for behaviors. The Activities of Daily Living (ADL) Plan of Care, dated 12/16/19, indicated Resident #1 required one or two caregivers, if he/she became combative, to assist with dressing. The Facility's Internal Investigation, dated 12/19/19, indicated that unbeknownst to the Facility, Family Member (FM) #1 placed a hidden camera in Resident #1's bedroom. The Investigation indicated FM #1 came to the facility on [DATE], and that FM #1, along with the Assistant Director of Nursing, the Nurse Case Manager, the Director of Admission and local law enforcement, watched the video footage that was obtained from the hidden camera. The Investigation indicated, that FM #1's video from 12/18/19, depicted CNA #1, who was alone with Resident #1 in the beginning of the video, was attempting to provide Resident #1 with evening personal care, Resident #1 was resistive to care, and that CNA #1 did hit Resident #1. During interviews with the Surveyor on 12/23/19, the Assistant Director of Nursing, Nurse Case Manager, and the Director of Admissions said they watched the video footage with FM #1 and local law enforcement and said they saw CNA #1 physically abuse Resident #1. Review of the video footage provided by Family Member (FM) #1, and date stamped 12/18/19, depicted CNA #1 physically and verbally abuse Resident #1. The video footage depicted the following: - 18:02:52 Resident #1 was sitting in a wheelchair and a staff member (later identified as CNA #1) attempted to assist Resident #1 with dressing. - 18:03:13 CNA #1 attempted to provide Resident #1 assistance with dressing and Resident #1's right hand can be seen grabbing at CNA #1's left gloved hand. CNA #1 pulled her left hand away from Resident #1, raised her right arm over her head and hit the left side of Resident #1's upper left extremity with her right hand. The audio portion of the video, is clearly audible and you can hear the sound of Resident #1 being slapped by CNA #1, when CNA #1's hand makes contact with Resident #1's body. After being hit, Resident #1 yells out, Son of a [***] . - 18:03:18 to 18:03:36 CNA #1 raised a pointed finger towards Resident #1 and she said, Don't you ever, ever put your finger in my face. Resident #1 said, I'm angry. CNA #1 continued to stand near Resident #1 and CNA #1 then said, Son of a [***] , I don't know you, don't you ever, ever. - 18:03:37 to 18:03:58 CNA #1 puts her left hand on Resident #1's wheelchair and wheeled him/her backwards away from her (CNA #1) and bent down over Resident #1 to confront him/her. CNA #1 said I know don't know you, huh, why did you try to hit me, why? CNA #1 then stands up straight, takes a step back away from Resident #1 and places her left hand on her left hip, and continues looking down at Resident #1, as if waiting for Resident #1 to respond. - 18:04:22 to 18:04:38 CNA #1 then sits down in a chair next to Resident #1. Resident #1 said, Son of a [***] . CNA #1 said, Why you call people a son of a [***] ? Resident #1, does not respond to CNA #1, but is seen fidgeting and leans forward in his/her wheelchair. CNA #1 then said Stop it, stop it. Resident #1 continues to fidget, is agitated, and managed to pull his/her shirt off enough to expose his/her upper torso, with his/her arms still in the sleeves. CNA #1 can then be seen trying to grab Resident #1's shirt and forcefully pull it away from him/her. - 18:04:39 to 18:04:59 Resident #1's arms are still inside his/her shirt sleeves and his/her upper torso remained exposed. Resident #1 yells out, Hurry up quick, they're bringing two knights. CNA #1 said, Two knights, while laughing. Resident #1 said, Two[***]. CNA #1 said, Two[***], two knights, and continues to laugh and mimic what Resident #1 says. Resident #1, who was extremely agitated, yelled out, They're trying to hang me. 18:05:31 Resident #1 removed his/her arms from his/her shirt, then yells out Get the hell out of here. 18:05:41 to 18:05:55 CNA #1 can then be seen coming up from behind Resident #1 and places a hospital gown over his/her head. Two staff members (later identified as Nurse #2 and CNA #2) then come into the view of the camera to help assist with Resident #1 with personal care. During an interview on 12/24/19 at 9:40 [NAME]M., CNA #1 said that on 12/18/19, she received report at the beginning of her shift from Nurse #2 that Resident #1 can be combative while providing assistance with care and said she was instructed not to provide care to Resident #1 alone. CNA #1 said she wheeled Resident #1 into his/her bedroom to provide care. CNA #1 said she started to take Resident #1's shirt off, but Resident #1 resisted care, and said she stepped back to wait for CNA #2 to come and assist her with providing care to Resident #1. CNA #1 said Resident #1 attempted to slap her, so she moved her arms to block Resident #1 from hitting her, and her hand went to Resident #1's head. CNA #1 said she told Resident #1, Don't you dare hit me again. On 12/23/19, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: [NAME] Resident #1 no longer resides at the Facility. B. 12/19/19 - Facility assessed all residents for the potential to be adversely affected by concern area, abuse by staff. C. 12/19/19 - Skin assessments were conducted on all residents by clinical staff. D. 12/19/19 - Resident interviews were conducted to ensure safety and for any concerns, by clinical and management staff. E. 12/19/19 - 12/22/19 - Nursing staff were in-serviced with mandatory training about the abuse policy, bathing difficult residents, recognizing abuse and staff burn out, bathing difficult residents, and assessing and developing care plans for resident behaviors. F. 12/19/19 Resident records were audited to identify behaviors and ensure care plans were developed and followed. [NAME] 12/19/19 - 12/20/19 Management staff completed hourly surveillance rounds for a 24 hour period throughout the entire building and will continue random surveillance for the care concern area, abuse by staff. H. QAPI meeting conducted 12/19/19, and concern area discussed with committee weekly for the next three weeks and then for two months to ensure substantial compliance is met. I. The Director of Nursing and his/her designee was responsible for overall compliance.