Every finding on record at Care One at Newton

Based on interviews and records reviewed, for one of seven sampled residents (Resident #7), who had been issued of Notice of Intent to Discharge and was to be transferred to another long-term care facility, the Facility failed to ensure they provided written notices of intent to discharge to the Office of the Long-Term Care Ombudsman, as required. Findings include: Review of the Facility Transfer and Discharge Policy, dated as revised March 2025, indicated that residents had the right to remain in the Facility and residents had the right to appeal discharge and transfer through the state agency that handles appeals upon receipt of a written notice of transfer or discharge. Review of Resident #7's medical record indicated that he/she was admitted to the Facility during June 2025 with diagnoses that included depression and anxiety. Review of Resident #7's Quarterly Minimum Data Set (MDS) Assessment, dated 2/26/26, indicated his/her cognitive patterns were intact. Resident #7's record contained a 30-Day Notice of Intent to Discharge, dated 3/31/26. The Notice indicated it was hand delivered to Resident #7 on 3/31/26 at 2:50 P.M. and notified him/her of the Facility's determination that a discharge was necessary for Resident #7's welfare because the Facility could not meet his/her needs. The Notice indicated the Facility intended to discharge Resident #7 to another long-term care facility on 4/30/26. Resident #7's record contained no documentation to support that the Facility had provided a copy of the Notice of Intent to Discharge Resident #7 to the Office of the Long-Term Care Ombudsman. During an interview on 4/07/26 at 11:00 A.M., Resident #7 said that the Facility handed him/her the Notice of Intent to discharge on [DATE]. Resident #7 said that when he/she contacted the Ombudsman about the Notice, the Ombudsman told him/her that their office had not received a copy of the Notice. During an interview on 4/02/26 at 9:30 A.M., the Ombudsman said that the Facility had not provided the Ombudsman office with a copy of the Notice of Intent to Discharge Resident #7. In an email on 4/06/26, the Ombudsman confirmed that the Ombudsman office still had not received a copy of the Notice of Intent to Discharge Resident #7, During an interview on 4/06/26 at 3:05 P.M, the Assistant Administrator said that he or his designee generally faxed discharge notices to the Office of the State Long-Term Care Ombudsman, however he could not find any documentation to support that the Facility had done so for Resident #7.

Based on records reviewed, photographs reviewed, and interviews, for three of three sampled residents (Residents #1, #2, and #3), who were cognitively impaired and dependent on staff for care, the Facility failed to ensure they protected their rights to respect and dignity, when on 10/16/25 and 10/17/25, a staff member took pictures of them and sent them via text message to a non-staff person, without their knowledge or consent. Findings include: Review of the Facility's Policy titled, Videotaping, Photographing and Other Images of Resident, dated as revised February 2021, indicated that transmitting unauthorized images of any resident through email, internet, or social media is considered a violation of resident rights. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/20/25, indicated that someone from the Board of Registration of Nursing (BORN) called the Facility and notified them that they (BORN) opened a case against Nurse #1 after receiving an allegation that Nurse #1 took photographs of residents and sent them to a non-staff person via text message. The Report indicated that although Nurse #1 initially denied the allegation, after further conversations with BORN and Nurse #1, they (Facility) determined that Nurse #1 had taken pictures of Residents #1, #2, and #3 and texted them to a non-staff person. Review of the Facility's Internal Investigation, undated, indicated that Nurse #1 took pictures on 10/16/25 and 10/17/25 of Residents #1, #2, and #3 with her cell phone and sent them via text message to a non-staff person. The Investigation indicated that Nurse #1 initially denied taking photographs of the residents and sending them via text to a non-staff person, she (Nurse #1) then admitted she had, and agreed to delete the pictures from her cell phone. The Investigation indicated that upon review of the photographs, the Facility was able to determine that the photographs were of Residents #1, #2, and #3. Review of photographs from a cell phone text thread provided by BORN, indicated that Nurse #1 sent photographs of Residents #1, #2, and #3 to a non-staff person on 10/16/25 and 10/17/25. The Assistant Director of Nurses (ADON), who also saw the photographs, was able to confirm and identify the individuals for the surveyor, as being Resident #1, Resident #2, and Resident #3. The ADON described what was depicted in the photographs as the following:-Resident #1 standing in the hallway, fully clothed,-Resident #2 sitting on the floor in the hallway, wearing a johnny and brief, and -Resident #1 lying wearing a johnny and covered with bed linens. Resident #1 was admitted to the Facility in June 2025, diagnoses included dementia. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 12/05/25 indicated that he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. Resident #2 was admitted to the Facility in June 2025, diagnoses included traumatic brain injury and vascular dementia. Review of Resident #2's Minimum Data Set (MDS) Quarterly Assessment, dated 12/05/25, indicated that he/she had moderate cognitive impairment and was dependent on staff to meet his/her care needs. Resident #3 was admitted to the Facility in June 2025, diagnoses included vascular dementia and failure to thrive. Review of Resident #3's Minimum Data Set (MDS) Quarterly Assessment, dated 10/31/25 indicated that he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. Residents #1, #2, and #3 were non-interviewable due to their cognitive impairment. The Surveyor was unable to interview Nurse #1, as she had retained legal counsel. During an interview on 02/10/26 at 11:26 A.M., the Assistant Director of Nurses (ADON) said that Nurse #1 allowed her to look through her (Nurse #1's) cell phone with her, and that she (ADON) was able to retrieve photographs of Residents #1, #2, and #3 from a text thread sent to a non-staff person. The ADON said she instructed Nurse #1 to immediately delete the photographs while in her presence and she (Nurse #1) did. During a telephone interview on 02/25/26 at 2:13 P.M., the Director of Nurses (DON) said that on 12/05/25, BORN notified the Facility that they had received an allegation involving Nurse #1. The DON said after several calls with BORN, it became evident that Nurse #1 took photographs of residents and sent them via text to a non-staff person The DON said that the ADON said she saw the photographs on Nurse #1's phone and instructed her (Nurse #1) to delete them immediately. The DON said that after Nurse #1 disclosed who she sent the photographs of Residents #1, #2, and #3 to, the Facility spoke with the recipient of the photographs and requested that the individual delete them and provide an email indicating that all resident photographs had been deleted from his phone, which he did. During a telephone interview on 02/10/26 at 2:35 P.M., the Administrator said she was not aware that Nurse #1 had taken photographs of residents and sent them via text, until BORN called and notified the Facility. The Administrator said they had several calls with BORN and received additional information about the allegation on 12/11/25. The Administrator said that the ADON said she saw the photographs on Nurse #1's cell phone and identified Residents 1, #2, and #3. The Administrator said Nurse #1 was suspended pending the investigation, was then re-educated and allowed to return to the Facility with the agreement that she must turn her cell phone into Administration prior to the start of her shift. The Administrator said that Nurse #1 had violated these residents' rights and had not followed Facility policy. On 02/10/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 12/23/25 which addressed the area(s) of concern as evidenced by:A. The Facility suspended Nurse #1 on 12/05/25, pending an investigation.B. The Facility provided support to Resident #1, #2 and #3, monitored them for changes in routine or changes in behavior patterns, and determined that they were not exhibiting any adverse effect associated with the deficient practice, due to their cognitive impairments.C. On 12/11/25, Residents on the unit where Nurse #1 worked and could have also been potentially affected by the deficient practice were interviewed, no concerns were reported.D. From 12/11/25 to 12/15/25, the ADON and/or designee conducted mandatory staff education on HIPAA, and the Facility's Resident Rights and Abuse Policies.E. The ADON and/or designee will conduct up to 10 random staff questionnaires weekly to ensure staff understands the education, to ensure compliance.F. On 12/11/25, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, and concern areas were discussed.G. On 12/19/25 the DON and/or designee initiated random audits/observations of staff phone usage on resident units, to continue for three weeks, and then monthly to monitor for compliance.H. On 12/23/25, Nurse #1 received additional training on Resident Rights, HIPAA, and Abuse before she was allowed to return to work, from the ADON and/or designee. Nurse #1 must also turn in her cell phone, to an administrative staff member, prior to the start of her shift and is not allowed to have it in her possession when on resident units.I. The results of the audits will be reviewed at the next monthly QAPI meeting.J. The Administrator and/or Designee are responsible for overall compliance

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), who was medically compromised, the facility staff failed to ensure a physician ordered antibiotic medication, which was available in the facility's emergency medical supply, was administered in a timely manner, placing him/her at risk for a worsening condition.Findings include:Review of the facility's policy, titled Charting and Documentation, with a revision date of 06/2017, indicated the following:-All services provided to the resident, progress toward the care plan and goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.-The following information is to be documented in the resident's medical record:*Medications administered.Resident #1 was admitted to the facility in June 2025, diagnoses included multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis (paralysis/weakness) following a cerebral infarction affecting his/her left side.Review of Resident #1's Nursing Progress Note, dated 10/05/25 at 7:17 P.M., indicated Resident #1 had a reddened genital area with swelling which was tender to touch. The [on-call] Nurse Practitioner was notified and gave an order to start Levofloxacin (antibiotic) 500 milligrams (mg) daily for 10 days and for Resident #1 to be seen the following day by a Nurse Practitioner or Physician.Review of Resident #1's Medication Administration Record (MAR) for the month of October 2025, indicated the first dose of Levofloxacin was not administered to him/her until 10/06/25 at 9:00 A.M. (14 hours after the order was received).Review of the lists of medications available at the facility from both the everyday medication dispensing machine and the emergency medication dispensing machine, indicated Levofloxacin 500 milligram tablets and/or Levofloxacin 250 mg tablets were available.During an interview on 12/31/25 at 3:55 P.M., Nursing Supervisor #1 said that he was on duty on 10/05/25 and obtained the order for Resident #1's antibiotic from the on-call Nurse Practitioner. Nursing Supervisor #1 said that he entered the order in Resident #1's Medication Administration Record (MAR) with the first dose to be given the following morning (10/06/25) because he thought that was what he was supposed to do.During a telephone interview on 01/02/26 at 10:25 A.M., Physician #1 said he had reviewed Resident #1's medical record [the Nurse Practitioner no longer works for the company] and said the first dose of the antibiotic should have been administered on 10/05/25, the evening the order was given to nursing.During a telephone interview on 01/02/26 at 1:28 P.M., the Director of Nurses (DON) said all medications administered by nursing are documented on the residents' MAR. The DON said when a nurse receives a new antibiotic order, the first dose should be administered to the resident. The DON said he considered 7:00 P.M. and thereabouts, a reasonable time and that Resident #1 should have received his/her first dose of the Levofloxacin on the evening of 10/05/25.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), who was medically compromised and had orders for blood laboratory work to be obtained, the facility staff failed to ensure his/her abnormal laboratory values were reported to his/her physician by nursing in a timely manner, placing him/her at risk for complications.Findings include:Review of the facility's policy, titled Change in Resident's Condition or Status, with a revision date of 02/2021, indicated the nurse will notify the resident's attending physician or physician on-call when there has been a significant change of condition that will not normally resolve itself without intervention by staff of by implementing standard disease-related clinical interventions (is not self-limiting).Resident #1 was admitted to the facility in June 2025, diagnoses included multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis (paralysis/weakness) following a cerebral infarction affecting his/her left side.Review of Resident #1's medical record indicated he/she had a physician's order, dated 10/03/25, to obtain a laboratory test for Sedimentation Rate (ESR, a blood test used to identify inflammation), C Reactive Protein (CRP, a blood test used to identify inflammation, elevated levels may indicate acute inflammation), and Basic Metabolic Panel (BMP).Review of Resident #1's laboratory results, dated 10/03/25, which were reported to the facility on [DATE] at 11:25 A.M., indicated the following:-Sedimentation Rate (ESR) result 99 mm/hr (millimeters per hour) High- normal range is 0-15 mm/hr-C Reactive Protein (CRP) result >80 mg/l (milligrams per liter)- normal range is 0.0-9.9 mg/lReview of Resident #1's medical record indicated there was no documentation to support that Resident #1's physician had been notified of the abnormal laboratory results.Review of Resident #1's Wound Physician's Evaluation and Management Summary, dated 10/06/25, indicated the following:-Resident #1 had cellulitis of the genital area (for at least one day).-Resident #1 had a new (less than one day) autoimmune disease-induced wound of the left thigh measuring 5 centimeters (cm) x 5 cm x 0.1 cm with a moderate amount of serous exudate (pale yellow drainage).-Further review of the Summary indicated Wound Physician #1 reviewed Resident #1's laboratory values and due to his/her elevated ESR and CRP levels, the Physician indicated Resident #1 needed to be transferred to the Hospital Emergency Department (ED) for further evaluation and intravenous antibiotic.Review of Resident #1's Nursing Progress Note (written by Nurse #1), dated 10/05/25 at 10:43 P.M., indicated Resident #1 had labs drawn and Nurse #1 had been calling the Doctor's number on profile and had not received a call back yet.The Surveyor was unable to interview Nurse #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview.Review of Resident #1's Nursing Progress Note (written by Nursing Supervisor #1), dated 10/05/25 at 7:17 P.M., indicated Resident #1 had a reddened genital area with swelling which was tender to touch. The [on-call] Nurse Practitioner was notified and gave an order to start Levofloxacin (antibiotic) 500 milligrams (mg) daily for 10 days and for Resident #1 to be seen the following day by a Nurse Practitioner or Physician.During an interview on 12/31/25 at 3:55 P.M., Nursing Supervisor #1 said that he was on duty on 10/05/25 and obtained the order for Resident #1's antibiotic from the on-call Nurse Practitioner. Nursing Supervisor #1 said if he had reviewed Resident #1's laboratory results he would have documented that he had done so in the Nursing Progress Note.During a telephone interview on 01/02/26 at 10:25 A.M., Physician #1 said he had reviewed Resident #1's medical record [the Nurse Practitioner no longer works for the company] and there was no documentation to support that Resident #1's lab results were reported a provider. Physician #1 said he would have expected the lab results to have been reported when the on-call Nurse Practitioner was updated with Resident #1's new clinical findings on 10/05/25.During a telephone interview on 01/02/26 at 10:05 A.M., Wound Physician #1 said he had ordered labs that were drawn on 10/03/25 for Resident #1 due to his/her chronic wound infections. Wound Physician #1 said abnormal lab results should be called in to the resident's primary care provider as he is only in the facility every Monday. Wound Physician #1 said that it was not uncommon for him and the primary care providers to collaborate on a plan of care based on lab results and said he was not notified of Resident #1's lab results until he was in the facility to evaluate him/her on 10/06/25.Wound Physician #1 said Resident #1's lab results indicated an acute on-chronic condition and the new wound on his/her thigh may have been related to the genital area edema. Wound Physician #1 said he determined that Resident #1 needed to be transferred to the Hospital Emergency Department (ED) for evaluation and treatment.During a telephone interview on 01/02/26 at 1:28 P.M., the Director of Nurses said when the nurses receive residents' abnormal lab results, they are responsible for notifying the provider and are supposed to document in the resident's medical record that the provider was notified and if there were changes in orders or not.

Based on records reviewed, observations, and interviews for three of five sampled residents (Resident #3, Resident #4, and Resident #5), who required specific infection control precautions, the facility failed to ensure staff providing direct care (Certified Nurse Aides) implemented and followed infection control precautions which included the need to wear the appropriate Personal Protective Equipment (PPE) during the provision of care.Findings include:1) Review of the facility's policy, titled Enhanced Barrier Precautions, dated 12/2024, indicated the following:-Enhanced Barrier Precautions (EBP) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.-EBP applies when a resident has a wound or indwelling medical device.-Gloves and gowns are applied prior to performing the high contact resident care activity.-Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs include:*dressing*providing bed mobility*changing linen*providing hygiene or grooming-Signs are posted on the door or wall outside the residents' rooms which will communicate the type of precautions and PPE required.Resident #3 was admitted to the facility in August 2025, diagnoses included Benign Prostatic Hyperplasia (BPH) with indwelling urinary catheter (a tube inserted into the bladder to allow drainage of urine) and sacral pressure injury.Review of Resident #3's Care Plan for use of indwelling urinary catheter, renewed and reviewed with last Minimum Data Set (MDS) assessment, indicated an intervention for staff to maintain Enhanced Barrier Precautions.During an observation and interview on 12/31/25 at 1:00 P.M., the surveyor observed a sign outside of Resident #3's room indicating he/she required EBP. The surveyor observed Certified Nurse Aide (CNA) #1 in Resident #3's room, without a gown on, adjusting his/her bed linens and repositioning him/her in bed.CNA #1 said she only needed to wear a gown when she was assisting the nurses with Resident #3's wound care. CNA #1 said she did not need to wear a gown when she was providing care for him/her.2) Review of the facility's policy, titled Isolation-Categories of Transmission-Based Precautions, dated 09/2022, indicated Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.-Staff and visitors wear gloves when entering the room and remove them before leaving the room.-Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room.Resident # 5 was admitted to the facility in October 2025, diagnoses included Methicillin Resistant Staphylococcus Aureus (MRSA- a drug-resistant organism), tracheostomy (a surgical opening into the windpipe to allow for breathing), and urinary retention with use of an indwelling urinary catheter.Review of Resident #5's Physician's Orders for the month of December 2025, indicated he/she had an order for Contact Precautions due to MRSA in his/her respiratory [tract] and Multiple Drug Resistant [organism] in his/her urine.During an observation and interview on 12/31/25 at 1:09 P.M., the surveyor observed a sign outside of Resident #5's room indicating he/she required Contact Precautions. The surveyor observed Certified Nurse Aide (CNA) #2, without a gown on, seated next to Resident #5's bed, assisting him/her to eat.CNA #2 said she thought she should have worn a gown when she was in Resident #5's room but said she did not wear one because no one told her what type of precautions Resident #5 required.3) Review of the facility's policy, titled Infection Prevention and Control Program, dated 12/2023, indicated important facets of infection prevention include:-Implementing appropriate enhanced barrier and transmission-based precautions when necessary.-Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).Resident #4 was admitted to the facility in December 2025, diagnoses included pancytopenia (low levels of red and white blood cells and platelets- causing fatigue and increased risk of infections and bleeding), colostomy (a surgical opening into the colon to allow for passage of stool), and acute and subacute endocarditis (infection of the heart's inner lining).During an observation and interview on 12/31/25 at 1:13 P.M. the surveyor observed a sign outside of Resident #4's room indicating he/she required Neutropenic Precautions which include:-Hand Hygiene when entering the room and before leaving the room.-Apply gloves before entering the room and remove them before leaving the room.-Apply a gown before entering the room and remove it before leaving the room.-Apply a mask before entering the room if you have a respiratory infection.-The patient may leave the room if wearing a mask.The surveyor observed Certified Nurse Aide (CNA) #3 enter Resident #4's room without applying gloves or gown, he proceeded into Resident #4's room, then turned back and applied a pair of gloves but no gown, then proceeded back into his/her room.Certified Nurse Aide #3 said that he only wore gloves when he provided care to Resident #4 and thought he needed a gown and a mask but did not wear either of them because he forgot to.During an interview on 12/31/25 at 2:20 P.M., the Director of Nurses (DON) said that all three residents (Resident #3, Resident #4, and Resident #5) were on different infection control precautions and that he expected the staff to implement and follow the appropriate precautions and wear the appropriate PPE per the signage on each resident's doorway.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication with a black box warning, the facility failed to ensure the dispensing Pharmacist and the Pharmacy Consultant identified and reported a medication that was prescribed and administered at an excessive frequency, which resulted in Resident #1 experiencing an overall decline in condition, requiring transfer and admission to the hospital.Findings include:Review of the facility's policy, titled Pharmacy Services Overview, with a revision date of 04/2019, included the following:-Pharmaceutical services consist of:*the processes of receiving and interpreting prescriber's orders; receiving, reconciling, and dispensing.all medications.*the process of identifying, evaluating and addressing medication-related issues including the prevention and reporting of medication errors.-The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.Review of the website, accessdata.fda.gov, approved by the U.S. Food and Drug Administration (FDA) indicated the following:-The recommended frequency to administer Methotrexate for both the treatment of psoriasis and rheumatoid arthritis, is weekly.-Methotrexate has a black box warning (the most serious warning the FDA uses to alert consumers and providers of possible risks associated with the use of this medication).-Taking more Methotrexate than prescribed or taking Methotrexate more often than prescribed, can lead to severe side effects and cause death.-If too much Methotrexate is consumed, immediate medical care is required to help reduce side effects that could be severe and could cause death.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, 10 tablets by mouth [once] every 7 days (5 tablets in the morning and 5 tablets in the evening, for a total dose of 25 mg). Review of Resident #1's Physician's Orders for the month of July 2025, indicated there was order to administer Methotrexate 2.5 mg, give 5 tablets by mouth two times a day (9:00 A.M. and 5:00 P.M.) for RA (Rheumatoid Arthritis). The order also included the following information: hazardous drug, wear gloves and wash hands thoroughly after handling. Pregnant women should avoid contact with this medication. During an interview on 09/03/25 at 1:04 P.M., Nurse #1 said he reconciled Resident #1's medications upon his/her admission to the facility and entered the medications in his/her Electronic Medical Record (EMR). Nurse #1 said that Physician #1 had previously reviewed and approved Resident #1's medications which were listed on his/her Hospital Discharge Summary.Nurse #1 said he made an error when he entered the medication in Resident #1's EMR and instead of entering the Methotrexate to be given in the morning and at night once per week, he entered for it to be given in the morning and at night every day.Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025 indicated for the Methotrexate he/she received 25 mg total on the following:-07/23/25 to 07/25/25, 25 mg daily-07/26/25, 12.5 mg daily-07/27/25 to 07/30/25, 25 mg daily-07/31/25, 12.5 mg dailyDuring a telephone interview on 09/04/25 at 12:16 P.M., the Pharmacy Director said that 120 tablets of Methotrexate were dispensed for Resident #1 upon receiving his/her admission orders from the Facility.The Pharmacy Director said that Resident #1's Methotrexate order was flagged for a Drug Utilization Review (DUR) and the Pharmacist who dispensed the medication, overrode the DUR alert. The Pharmacy Director said the DUR alert was triggered to alert the dispensing Pharmacist to contact the Facility to verify the dose and frequency of the Methotrexate order.The Pharmacy Director said, had the contact with the Facility taken place and the medication verified, this error would likely have been discovered before the medication was sent out to the Facility.Review of Resident #1's Interim Medication Regimen Review, dated 07/24/25, indicated a Pharmacy Consultant reviewed Resident #1's physician's orders and did not identify or report the order for Resident #1 to receive Methotrexate 25 milligrams (total dose) by mouth daily.During a telephone interview on 09/04/25 at 12:16 P.M., the Pharmacy Director said the Pharmacy Consultant reviewed Resident #1's medications on 07/24/25 and the excessive dosing in the Methotrexate order should have been identified and reported as inappropriate.Review of Resident #1's Nursing Progress Note, dated 07/31/25, indicated he/she had acute respiratory distress, increased congestion, decreased blood oxygen level despite the use of oxygen, loose bowel movements, and decreased food/fluid intake. The Note indicated he/she was transferred to the Hospital Emergency Department (ED) for an evaluation.Review of Resident #1's Hospital Progress Note, dated 08/03/25, indicated he/she had pancytopenia (low red blood cells-carry oxygen; low white blood cells- fight infection, and low platelets- for blood clotting) likely due to chronic methotrexate toxicity. The Note indicated pancytopenia occurred acutely within the span of 10 days (7/21/25 through 07/31/25); and his/her Methotrexate level that day was 0.29, (levels greater than 0.10 after 24 hours of administration of the medication would be considered toxic).Further review of the Note indicated that Poison Control recommended to continue to administer leucovorin 25 milligrams every six hours and obtain daily methotrexate levels until the level was <0.01.During an interview on 09/03/25 at 3:24 P.M., the Director of Nurses (DON) said that the Pharmacy did not identify the error related to Resident #1's Methotrexate order at any point and should have. The DON said that he had received the Pharmacy's investigation related to this medication error, including their action plan.On 09/03/25, the Facility was found to be in Past Non-Compliance, with an effective date of 08/30/25, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 08/08/25 and 08/12/25, the Pharmacy Director educated the Pharmacists on the appropriate dose and frequency for the administration for Methotrexate.B) On 08/11/25 the Pharmacy Director educated all Pharmacy order entry staff on Methotrexate dosing guidelines and when to report to the staff pharmacist on duty.C) All Pharmacists will complete two continuing education hours on preventing medication errors with their annual requirements.D) On 08/04/25 through 08/20/25, the Staff Educator educated the nursing staff on accurately transcribing medication orders for new admissions and readmissions to the facility, and the new system/process regarding Que orders.E) On 08/04/25, the Facility implemented a new system, the admitting nurse will enter the orders in the Electronic Medical Record, a second nurse will verify with the discharge summary and activate the orders.F) On 08/04/25 an audit was initiated for all current new admissions and readmissions for the previous 30 days for admissions medication transcription accuracy.G) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.H) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.I) On 08/04/25, the unit managers or designee will review the medication reconciliation forms within 24 hours of admission or readmission to ensure they are complete, accurate, and all areas of conflict were addressed with the MD or provider.J) On 08/04/25 through 08/30/25, the licensed staff will review resident admitted in the last 30 days to ensure the medication reconciliation is completed and any potential conflicts are reported and resolved.K) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.L) On 08/15/25, audits to ensure the medical reconciliation was completed were initiated and are on-going by the Director of Nurses or designee.M) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.N) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included administration of a potentially toxic medication (oral chemotherapy agent used to treat rheumatoid arthritis) the facility failed to ensure he/she was free from a significant medication error, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered the medication for consecutive days in error. Resident #1 experienced an overall decline in condition, was transferred and admitted to the Hospital, and was treated for toxic levels of the medication. Findings include:Review of the Facility's policy, titled Adverse Consequences and Medication Errors, with a revision date of 06/2025, indicated the following:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional (s) providing services.-A significant medication-related error is defined as requiring medication discontinuation; requiring hospitalization; requiring treatment with a prescription medication; life threatening and/or resulting in death.-Evaluate the resident for possible medication-related adverse consequences when the resident has a significant change in clinical condition/status including unexplained decline in function, cognition or behavior; or worsening of an existing problem or condition.Review of the Facility's policy, titled Medication Reconciliation, with a revision date of 12/2014, indicated the following:-The Center will accurately reconcile medications of newly admitted residents to contribute to the creation of an accurate medication list.-Prescribing errors may occur when a patient is admitted to the hospital or transferred across the continuum of care to the skilled nursing center; these errors may result in adverse drug events.-Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient's current medication (including name, dosage, frequency, and route) and comparing the incoming admission, transfer and or discharge medication orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders.Review of the website, accessdata.fda.gov, approved by the U.S. Food and Drug Administration (FDA) indicated the following:-The recommended frequency to administer Methotrexate for both the treatment of psoriasis and rheumatoid arthritis, is weekly.-Methotrexate has a black box warning (the most serious warning the FDA uses to alert consumers and providers of possible risks associated with the use of this medication).-Taking more Methotrexate than prescribed or taking Methotrexate more often than prescribed, can lead to severe side effects and cause death.-If too much Methotrexate is consumed, immediate medical care is required to help reduce side effects that could be severe and could cause death.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, take 10 tablets [25 mg] by mouth [once] every 7 days (5 tablets [12.5 mg] in the morning and 5 tablets in the evening).Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025, indicated he/she a physician's order to administer Methotrexate 2.5 mg, give 5 tablets by mouth two times a day (9:00 A.M. and 5:00 P.M.) for RA (Rheumatoid Arthritis). The order also included the following warning: hazardous drug, wear gloves and wash hands thoroughly after handling. Pregnant women should avoid contact with this medication. Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025 indicated for the Methotrexate he/she received 25 mg total on the following:-07/23/25 to 07/25/25, 25 mg daily-07/26/25, 12.5 mg daily-07/27/25 to 07/30/25, 25 mg daily-07/31/25, 12.5 mg dailyDuring an interview on 09/03/25 at 1:04 P.M., Nurse #1 said he entered the physician's orders in Resident #1's Electronic Medical Record (EMR) upon his/her admission to the facility. Nurse #1 said that Physician #1 had previously reviewed and approved Resident #1's medications which were listed on his/her Hospital Discharge Summary.Nurse #1 said he made an error when he entered the medication in Resident #1's EMR and instead of entering the Methotrexate to be given in the morning and at night once per week, he entered for it to be given in the morning and at night, every day.Nurse #1 said he was unfamiliar with the intended use and usual dosing for Methotrexate prior to this incident.During a telephone interview on 09/04/25 at 9:02 A.M., Physician #1 said he was in the facility when Resident #1 was admitted . Physician #1 said he had reviewed his/her Hospital Discharge Summary and that all the medications listed on the Summary were to be continued at the facility. Physician #1 said he was very familiar with Methotrexate and that it was to be administered weekly.Review of Resident #1's Nursing Progress Notes, indicated Nurse Practitioner (NP) #1 visited Resident #1 at the facility on 07/23/25 and 07/28/25.Review of Resident #1's NP Progress Notes indicated that on 07/23/25 and 07/28/25, NP #1 documented that Resident #1's Methotrexate order was as follows:-Methotrexate 2.5 milligrams- take 5 [tablets] by mouth everyday two times per day.During a telephone interview on 09/04/25 at 8:35 A.M., Nurse Practitioner #1 said that although he listed all of Resident #1's medications in his Progress Notes, he reviewed only the medications that were pertinent to his visits. NP #1 said that Methotrexate was managed by specialists, and he was not familiar enough with the recommended administration frequency to have questioned the directions as they were listed on Resident #1's physician's orders.Review of Resident #1's Nursing Progress Note, dated 07/31/25, indicated he/she had acute respiratory distress, increased congestion, decreased blood oxygen level despite the use of oxygen, loose bowel movements, and decreased food/fluid intake. The Note indicated he/she was transferred to the Hospital Emergency Department (ED) for an evaluation.Review of Resident #1's Hospital Progress Note, dated 08/01/25, indicated his/her Methotrexate was restarted in June 2025 after being on hold due to thrombocytopenia (a condition caused by low platelets, which can lead to easy bruising and bleeding).Review of Resident #1's Hospital Progress Note, dated 08/03/25, indicated he/she had pancytopenia (low red blood cells-carry oxygen; low white blood cells- fight infection, and low platelets- for blood clotting) likely due to chronic methotrexate toxicity. The Note indicated pancytopenia occurred acutely within the span of 10 days (7/21/25 through 07/31/25); and his/her Methotrexate level that day was 0.29 (levels greater than 0.10 after 24 hours of administration of the medication would be considered toxic) which is more consistent with chronic toxicity per Poison Control.Further review of the Note indicated that Poison Control recommended to continue to administer leucovorin (form of folic acid to help prevent side effects of certain medications) 25 milligrams every six hours and obtain daily methotrexate levels until the level was <0.01.During a telephone interview on 09/04/25 at 9:55 A.M., the Medical Director said he was disappointed that many of the systems in place to avoid medication errors such as this failed. The Medical Director said the medication orders listed on Resident #1's Hospital Discharge Summary should have been implemented and transcribed accurately.During an interview on 09/03/25 at 3:24 P.M., the Director of Nurses (DON) said Resident #1's Methotrexate order was not accurately transcribed in his/her medical record upon admission to the Facility. The DON said the manner in which the nursing staff performed their medication reconciliations was not in accordance with facility protocol.The DON said he expected the nursing staff to carefully and accurately transcribe orders and to be familiar with the medications they are administering.On 09/03/25, the Facility was found to be in Past Non-Compliance, with an effective date of 08/30/25, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 08/04/25 through 08/20/25, the Staff Educator educated the nursing staff on accurately transcribing medication orders for new admissions and readmissions to the facility, and the new system/process regarding Que orders.B) On 08/04/25, the Facility implemented a new system, the admitting nurse will Que the orders in the Electronic Medical Record, a second nurse will verify with the discharge summary and activate the orders.C) On 08/04/25 an audit was initiated for all current new admissions and readmissions for the previous 30 days for admissions medication transcription accuracy.D) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.E) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.F) On 08/04/25, the unit managers or designee will review the medication reconciliation forms within 24 hours of admission or readmission to ensure they are complete, accurate, and all areas of conflict were addressed with the MD or provider.G) On 08/04/25 through 08/30/25, the licensed staff will review resident admitted in the last 30 days to ensure the medication reconciliation is completed and any potential conflicts are reported and resolved.H) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.I) On 08/15/25, audits to ensure the medical reconciliation was completed were initiated and are on-going by the Director of Nurses or designee.J) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.K) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure his/her medical record was complete and accurate when 1) the Physician signed a medication order in error and 2) the Nurse Practitioner documented that all of Resident #1's medications were reviewed at each visit.Findings include:Review of the facility's policy, titled Charting and Documentation, with a revision date of 07/2017, indicated the following:-Documentation in the medical record will be objective, complete, and accurate.-Electronic entries that are auto-filled, or auto-prompts must be reviewed and updated when more current information is available or required; or accepted as it is after review.Review of the facility's policy, titled Medication and Treatment Orders, with a revision date of 07/2016, indicated the following:-Orders for medications and treatments will be consistent with principles of safe and effective order writing.-The signing of orders shall be by signature or a personal computer key.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, take 10 tablets by mouth every 7 days (5 tablets in the morning and 5 tablets in the evening).1) Review of Resident #1's Order Audit Report for his/her Methotrexate medication order indicated the following:-On 07/22/25 Nurse #1 entered a medication order for Methotrexate Tablet 2.5 milligrams -Give 5 tablets by mouth two times a day for R/A (Rheumatoid Arthritis).-The Methotrexate medication order was electronically signed by Physician #1 on 07/28/25.During a telephone interview on 09/04/25 at 9:02 A.M., Physician #1 said he was in the facility when Resident #1 was admitted . Physician #1 said he had reviewed his/her Hospital Discharge Summary and that all the medications listed on the Summary were to be continued at the facility. Physician #1 said he was very familiar with Methotrexate and that it was administered weekly.Physician #1 said that orders are sent to him electronically and often are received in bulk with 150 to 200 orders received at a time. Physician #1 said he had no reason to believe there had been a transcription error when nursing initially entered the orders for Resident #1 and therefore, he signed his/her order for Methotrexate to be administered twice daily instead of once weekly.2) Review of Resident #1's Nursing Progress Notes, indicated Nurse Practitioner (NP) #1 visited Resident #1 at the facility on 07/23/25 and 07/28/25.Review of Resident #1's NP Progress Notes indicated that on 07/23/25 and 07/28/25, NP #1 documented that Resident #1's Methotrexate order was as follows:-Methotrexate 2.5 milligrams- take 5 [tablets] by mouth everyday two times per day.During a telephone interview on 09/04/25 at 8:35 A.M., Nurse Practitioner #1 said that although he listed all of Resident #1's medications in his Progress Notes, he reviewed only the medications that were pertinent to his visits. NP #1 said that Methotrexate was managed by specialists, and he was not familiar enough with the recommended administration frequency to have questioned the directions as they were listed on Resident #1's physician's orders.During a telephone interview on 09/04/25 at 9:55 A.M., the Medical Director said he expected the providers to catch mistakes such as this Methotrexate medication order and that all entries made into the medical record must be right.During a telephone interview on 09/09/25 at 12:52 P.M., the Director of Nurses (DON) said he expected all medical record entries to be complete and accurate.

Based on observation and interview, the facility failed to provide a dignified experience for residents as evidenced by staff utilizing a resident bedroom for personal storage and documentation for one Resident, (#140), out of a total of 36 sampled Residents.Findings include: Review of the facility's policy titled “Dignity”, dated February 2021 indicated: Residents' private space and property are respected at all times. Resident #140 was admitted to the facility in June 2020 with diagnoses including Alzheimer's disease and heart disease. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #140 is severely cognitively impaired and dependent on staff for activities of daily living. On 7/16/2025 at 7:48 A.M., the surveyor observed Resident #140 asleep in bed. An iPhone was charging on his/her nightstand. On 7/16/2025 at 12:33 P.M., the surveyor observed Resident #140 asleep in bed. The iPhone was no longer on the nightstand. On 7/17/2025 at 6:55 A.M., the surveyor observed Resident #140 asleep in bed. There was an iPhone charging on his/her nightstand and a plastic bag of unknown personal items was on a chair. The phone’s alarm began sounding off and Resident #140 began adjusting in bed and raised his/her eyebrows at the noise. The alarm continued to sound for approximately five minutes before turning off. On 7/17/2025 at 7:01 A.M., the surveyor observed a Certified Nursing Assistant (CNA) exit Resident #140’s room holding the white plastic bag and leaving the unit. On 7/17/2025 at 12:09 P.M., the surveyor observed Resident #140 asleep in bed. CNA #1 was observed seated in a chair behind the door with an iPad (utilized for documentation) with his eyes closed. CNA #1 then opened his/her eyes and sat up straight and began to document on the iPad. On 7/17/2025 at 12:20 P.M., the surveyor returned to the room and observed Resident #140 asleep in bed and CNA #1 was seated behind the door holding his phone up and speaking aloud while holding the iPad. On 7/18/2025 at 6:54 A.M., the surveyor observed Resident #140 awake in bed. He/she was nonresponsive to the surveyor’s questions. A CNA was seated in a chair behind the door and documenting on her iPad. A white plastic bag of personal effects was on a chair. On 7/18/2025 at 6:59 A.M. the surveyor observed Resident #140 asleep in bed and the CNA had left the room. There was a pair of white croc shoes on the floor next to the chair the CNA was sitting on. On 7/18/2025 at 7:01 A.M., the surveyor observed the CNA ambulating into Resident #140’s room from the hallway and not wearing shoes. The CNA then exited the room wearing the white crocs and holding the white plastic bag and then left the unit. During an interview on 7/18/2025 at 10:11 A.M., Unit Manager #1 said that resident room space is private, and staff should not be keeping personal effects or making personal calls in resident rooms. Unit Manager #1 said that staff are to document at the nurses station and not in resident rooms. During an interview on 7/18/2025 at 10:18 A.M., the Assistant Director of Nursing (ADON) said that resident room space is personal and expect that staff should not store their personal effects in resident rooms, document or make personal phone calls in rooms. The Director of Nursing (DON) said that he was aware of the ongoing concerns about staff using phones on the units.

Based on observation and interview, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness.Findings includeReview of the facility polity titled, Food: Preparation and Service, undated, indicated the following:-Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.-Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross- contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods.-Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.On 7/18/25 from approximately 7:40 A.M. to 8:10 A.M., the following was observed in the facility kitchen during the breakfast meal line:-The Food Service Director (FSD) had on a pair of gloves and picked up a lid off the steam table, potentially contaminating his gloves. He then used the same gloved hand and picked up an English muffin and placed it on a plate to be served. He then used the same gloved hand to move a rolling food cart, grasping the handle and then picked up a breakfast sandwich and re-arranged it on a serving plate. The FSD then picked up a metal scoop to lift off the lid to the pureed food located on the steam table. He used the same potentially contaminated scoop to serve food to be placed on serving plates. He then picked up tongs with his gloved hands and then touched slices of cheese to be placed on the breakfast sandwiches. He then picked up the sandwiches with his potentially contaminated gloved hand. The FSD picked up eggs with his gloved hands and placed them on plates. He proceeded to touch plates, serving utensils, trays, and bowls, with his gloved hands. The FSD touched toast, English muffins, fried eggs, and placed items on a plate to be served to residents. The FSD did not remove his gloves or perform hand hygiene throughout this observation. -Dietary Aid #1 had one glove on his left hand and was observed moving a food cart across the kitchen placing his gloved hand on the food cart handles. He then used his potentially contaminated gloved hand to pick up clean serving plates placing his gloved fingers on the inside of the dishes. He then used his potentially contaminated gloved hand to pick up a toasted English muffin and place it on to a serving plate. Dietary Aid #1 was observed removing his contaminated glove and put on a new glove, (without performing hand hygiene). He was then observed picking up metal tongs with his gloved hand and then using the same gloved hand to remove bread from the conveyor toaster. He then removed his contaminated glove from this hand and did not perform hand hygiene. He then used his bare hands to move a breakfast cart and picked up bags of sliced bread with his bare hand. Dietary Aid #1 did not perform hand hygiene throughout the observation. -Dietary Aid #2 was observed picking up a white rag with his gloved hands to clean off the table by the conveyor toaster. He then used his contaminated gloved hand to pick up slices of bread to place them into the conveyor toaster. He then used his contaminated gloved hands to move a rolling food cart by touching the handles and then picked up the toasted English muffins with his potentially contaminated gloved hands. Dietary Aid #2 did not remove his gloves or perform hand hygiene throughout this observation. -Dietary Aid #3 had on a pair of gloves and picked up a knife by the handle and proceeded to cut English muffins. She then picked up a pair of tongs with her gloved hands and then picked up English muffins with her potentially contaminated gloved hands to be placed on a serving plate. Dietary Aid #3 did not remove her gloves or perform hand hygiene throughout this observation. During an interview on 7/18/25 at 10:44 A.M., Dietary Aid #1 said staff must wash their hands before and after glove use and said he should not be handling or touching food items with a contaminated glove. During an interview on 7/18/25 at 11:04 A.M., Dietary Aid #3 said she should not have touched food items with her gloves after touching equipment.During an interview on 7/18/23 at 10:50 A.M., the Food Service Director (FSD), said staff need to wash their hands prior to putting on gloves and then if gloves become contaminated by touching items other than food, the gloves must be changed, and hands should be washed again.

Based on observations, record reviews and interviews, the facility failed to ensure the residents of the facility were free from accidents. Specifically, the facility failed to:1.) Ensure a wander guard was in place and ensure the resident was not moved to a less secure unit, resulting in the elopement of one Resident, (#62), out of a total of 36 sampled Residents.2.) Respond appropriately to an open flame fire during breakfast service in the kitchen. Findings include: 1. Resident #62 was admitted to the facility in May 2025 with diagnoses including altered mental status and mild neurocognitive disorder due to physiological condition with behavioral disturbance. Review of Resident #62’s most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 7 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #62 requires supervision for all self-care and mobility tasks. During an interview on 7/16/25 at 9:15 A.M., Resident #62 was observed walking in his/her room independently. Resident #62 was unable to provide any history into his/her stay at the facility. During survey, the surveyor attempted to contact Resident #62’s guardian and did not receive a return call. Review of the incident report dated 6/21/25 indicated Resident #62 had eloped from the facility and had been missing for 4 hours before being found by the police. Review of Resident #62’s initial skilled nursing assessment dated [DATE] failed to complete the section addressing the Resident’s wandering status. Review of the nursing note dated 5/16/25 indicated: -“Resident noted to be pleasantly confused and goal driven to go to the bank. Resident ambulating independently with no assistive device. Allotment assessment initiated. Care plan updated. NP (Nurse Practitioner) aware. Room change to secure unit completed.” On 5/16/25, Resident #62 was transferred to a secure, code locked unit. Review of Resident #62’s elopement/wandering care plan initiated on 5/16/25, had a goal that the Resident would not leave the facility unattended and indicated the following interventions: -Room change to secure unit. -Engage resident in purposeful activity. -Identify triggers for wandering/elopement. -Identify if there is a certain time of day wandering/elopement attempts occur. Review of the skilled nursing assessments after Resident #62’s display of wandering behaviors indicated the following: -assessment dated [DATE] indicated Resident #62 wanders at night, however, failed to complete the other wandering sections or initiate a care plan intervention for the wandering behavior. -assessment dated [DATE] failed to complete any sections focused on wandering behaviors. -assessment dated [DATE] indicated Resident #62 wanders at night, however, failed to complete the other wandering sections or initiate a care plan intervention for the wandering behavior. --assessment dated [DATE] failed to complete any sections focused on wandering behaviors. Review of Resident #62’s elopement assessment dated [DATE] indicated the Resident had verbally expressed the desire to go home, packed belongings to go home or stayed by the exit door, had wandered on the unit, had a wandering behavior pattern that was goal directed, and has recently been admitted to the facility and is not accepting the situation. Review of the nursing note dated 5/22/25 indicated Resident #62 was at high risk of elopement and included the following: -“Resident is alert verbal and pleasantly confused able to make (his/her) needs known. Assist with ADL's (activities of daily living) cooperative. Out of bed and ambulates in unit using RW (rolling walker) gait is slow and steady. High risks for elopement wander in and out of (his/her) room. Socializing with another resident. From time to time will ask how to get home. Wants staff to call Uber for (him/her). Verbally redirect with good effects.” Review of the nursing note dated 5/26/25 indicated Resident #62 was at high risk of elopement and included the following: -“High risks for elopement wander in and out of (his/her) room. Socializing with another resident. From time to time will ask how to get home. Asking for (his/her) fiancé.” Review of the nursing note dated 6/11/25 indicated Resident #62 was at high risk of elopement and included the following: -“Resident is alert verbal and pleasantly confused able to make (his/her) needs known. Assist with ADL's cooperative. Out of bed and ambulates in unit gait is slow and steady. High risks for elopement wander in and out of (his/her) room. Belonging pack and asking about (his/her) car. Verbally redirect with poor effects. From time to time will ask how to get home. Family in to visit. Verbally redirect with good effects.” Review of the nursing note dated 6/17/25 indicated the following: -“Patient moved to [NAME] unit room [ROOM NUMBER]D with meds and belongings on 6/17/25. Nursing report was given to receiving nurse and stated understanding. Guardian was notified and agreed to room change.” Review of the physician orders indicated that on the same day Resident #62 was transferred off the secured, locked unit, the physician prescribed a wander guard (a device that would alarm if the Resident were to leave the new unit). Review of Resident #62’s elopement assessment dated [DATE], (the day after he/she was transferred off the secured code locked unit,) indicated the Resident had previous attempts at elopement in the facility, had verbally expressed the desire to go home, packed belongings to go home or stayed by the exit door, had wandered on the unit, had a wandering behavior pattern that was goal directed, and has recently been admitted to the facility and is not accepting the situation. Review of the Treatment Administration Record for June 2025 indicated that the wander guard was not in place on 6/18/25, 6/19/25, 6/20/25 or 6/21/25. The nursing notes failed to indicate that the clinical team was made aware of the missing wander guard. Review of the nursing note dated 6/21/25 indicated the following: -“Resident noted missing from the unit at around 4:40 PM. Code Gray activated. Staff responded. Unable to locate resident in the unit. Unable to locate the resident in the building nor facility grounds. Resident is care planned for 15 minute checks period last seen in the unit at around 4:30 PM walking in the hallway. MD and responsible party notified of the event. Local Police Department called to report a missing person. At approximately 8:00 PM police notified facility that BPD was able to locate the Resident at (his/her) home address. MD and responsible party updated. Residents sent to ER on section 12 for further evaluation.” During an interview on 7/18/2025 at 10:15 A.M., Unit Manager #2 said Resident #62 was moved off the secured, code locked unit secondary to him/her “doing better” and wanting to participate in more activities. Unit Manager #2 said she is unaware of the circumstances that led to Resident #62’s elopement from the facility. During an interview on 7/18/2025 at 10:57 A.M., the Assistant Director of Nursing said Resident #62 was transferred off the secured, code locked unit because the clinical team felt he/she had settled in and was needing to participate in activities more. The Assistant Director of Nursing said she was unaware of the nursing notes indicating the Resident had increased wandering behaviors and was a “high risk of elopement”. The Assistant Director of Nursing said that when Resident #62 was moved off of the unit, he/she was given a wander guard as an intervention to prevent elopement because it would alarm if the Resident went onto the elevator. The Assistant Director of Nursing reviewed the TAR from June 2025 with the surveyor and said the Resident did not have the wander guard in place at the time of elopement or for the couple days prior and she does not remember any of the nursing staff reporting the wander guard missing to the clinical team. During an interview on 7/18/2025 at 12:14 P.M., the Director of Nursing said Resident #62 was moved off the secured, code locked unit so that he/she could be closer to activities. The Director of Nursing said that at the time of the move, the facility was aware the Resident was a risk for elopement, and a wander guard was provided to him/her. The Director of Nursing said that if he was aware the Resident was displaying increased behaviors of elopement as the nursing notes indicated, he would not have agreed to the Resident being moved to a different unit. The surveyor and Director of Nursing reviewed the nursing notes that indicated the Resident was at high risk of elopement and was having increased behaviors and he said he was not aware of this. The Director of Nursing said that at the time of Resident #62’s elopement, Resident #62 was not wearing the wander guard as ordered and, after reviewing the TAR, said the nursing staff must have been aware of this and should have notified him. 2. Review of the facility policy titled “Fire Safety and Prevention”, dated as revised July 2024, indicated: fire prevention is the responsibility of all personnel residents’ visitors and the public. Review of the conveyor toaster user manual indicated the following: 12. Oversized bread, metal foil packages or utensils must not be inserted in a toaster as they may involve a risk of fire or electrical shock. 13. Do not attempt to dislodge food when toaster is plugged into electrical outlet. 14. To avoid possibility of fire, do not leave unattended during use. 23. Some exterior surfaces on the unit will get hot. Use caution when touching these areas to avoid injury. On 7/18/25 between 7:42 A.M. and 8:20 A.M., the surveyor made the following observations while watching the breakfast line: -At 7:42 A.M., and 7:55 A.M., The surveyor observed an open flame inside of the toaster on the conveyor belt. There was smoke coming from the toaster. The Dietary Aid walked away from the toaster leaving the open flame with burning toast on the conveyor belt unattended. Dietary Aid #2 walked over to the conveyor toaster picked up the metal tongs and removed the piece of bread that was on fire. The Dietary Aid did not unplug the toaster or notify anyone of the fire. -At 8:05 A.M., The surveyor observed Dietary Aid #2 place English muffins on to the conveyor toaster belt, then walked away from the conveyor toaster leaving kitchen area leaving the English muffins on the conveyor belt unattended. At 8:07 A.M., the surveyor observed an open flame inside of the toaster on the conveyor belt. There was smoke coming from the toaster. The English muffins began to smoke and fire with large growing open flames continued to grow, consuming the English muffin. The surveyor notified the Food Service Director (FSD) and Dietary Aid who were present in the kitchen yet did not notice the large fire inside of the toaster. Dietary Aid #1 was observed picking up metal tongs and placed them into the electric toaster attempting to remove the English muffin that was on fire inside of the toaster. The FSD was heard telling the dietary aid to “don’t stick metal into the toaster you need to unplug it first!” The open flame continued to burn, and fire was observed on the conveyor belt as smoke continued to come out of the toaster. The toaster had a tray place on top containing several plastic bags containing sliced bread and English muffins. The surveyor intervened and informed staff to remove the tray from the top of the conveyor toaster to avoid a potential second fire. During an interview on 7/18/25 at 10:45 A.M., Dietary Aid #1 said the toaster should not be left unattended and said he would use the fire extinguisher if the fire got any bigger to stop it from spreading. Dietary Aid #1 said this has happened before, but they are able to put out the fire by tapping the bread inside with a spoon or tongs. During an interview on 7/18/25 at 10:47 A.M., Dietary Aid #2 said he was not sure what to do because the toaster has never caught fire before. During an interview on 7/18/25 at 10:49 A.M., the FSD said staff should never leave the toaster unattended and said staff should unplug the unit and notify other staff if a fire has occurred. The FSD said he should have been notified when the first fire started and said the unit could have been inspected for food stuck on the belt and for proper management to prevent any additional fires. The FSD said metal tongs should never be placed inside the unit and said items should not be stored on top of a hot conveyor toaster because they could catch fire.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement occupational health policies prohibiting contact with residents or their food, evidenced by observations of Dietary Aide #1 working in the facility kitchen while having a skin injury on his hand which prevented him from being able to perform hand hygiene. Findings include:Review of the facility policy titled Employee Health Program, dated September 2022, indicated the following:Our facilities employee health program strives to promote the health safety and well-being of our personnel and prevent the spread of communicable diseases among staff and residents.-Providing employee screening for communicable diseases and infections-Employment physical examinations and testing shall focus on occupational health and remain relevant to job requirements in the workplace for example the nature and scope of an employee's physical limitations of endurance or strength is relevant only if his or her job responsibilities require physical endurance and or strength.-Employment examination shall also be used to screen employees for signs symptoms and or risk factors for communicable diseases.On 7/18/25 from approximately 8:10 A.M., the following was observed in the facility kitchen during the breakfast meal line:-Dietary Aid #1 had one glove on his left hand and was observed moving a food cart across the kitchen placing his gloved hand on the food cart handles. He then used his potentially contaminated gloved hand to pick up clean serving plates placing his gloved fingers on the inside of the dishes. He then used his potentially contaminated gloved hand to pick up a toasted English muffin and place it on to a serving plate. Dietary Aid #1 was observed removing his contaminated glove and put on a new glove. He did not perform hand hygiene.-Dietary Aid #1 was observed picking up metal tongs with his gloved hand and then using the same gloved hand to remove bread from the conveyor toaster. He then removed his contaminated glove from this hand and did not perform hand hygiene. He then used his bare hands to move a breakfast cart and picked up bags of sliced bread with his bare hand.The surveyor observed blue stitching located on Dietary Aid #1's left index finger. There was a laceration with stitches exposed on the outside of the finger and it was not covered.During an interview on 7/18/25 at 10:45 A.M. Dietary Aid #1 said he was injured about a week and a half ago at home requiring 10 stitches to his left index finger and said he cannot get the area wet and wears gloves to protect the stitches. Dietary Aid #1 said he told the Food Service Director (FSD) about his injury and said he wears a glove because he can't perform hand washing or use alcohol because of the open cut and stitches.During an interview on 7/18/25 at 10:53 A.M., the FSD said he did not know about the stitches and said he thought it was just a bad cut because he saw Dietary Aid #1 with a finger condom on it the other day. The FSD said the area should be covered with a bandage and not exposed to food. The FSD said he did not notify anyone about the open area to the finger. During an interview on 7/18/25 at 11:24 A.M., the Human Resource Director said she was not made aware of the employees' injury and said she should have been notified because the dietary aid needs to be cleared for work following stitches to his hands and said staff cannot work if they cannot wash their hands and perform work duties. During an interview on 7/18/25 at 11:46 A.M. the Director of Nurses (DON) said if staff report an illness or injury, we need to know to track it for infection control reasons to determine next steps. The DON said staff cannot work with open wounds and said standard infection control practices are facility wide and said he expects staff to follow hand washing guidelines and not report to work if open skin lesions are unable to be covered or contained. During an interview on 7/18/25 at 12:06 P.M., the Administer said the staff member should not have been working until he was cleared to do so and said staff should not be working with open wounds or stitches and said staff must be able to wash their hands appropriately.

Based on record review and interview, the facility failed to obtain informed consent prior to administering psychotropic medication for one Resident #129 out of a sample of 36 residents. Specifically, the facility failed to obtain legal informed consent from court prior to administering an antipsychotic medication.Findings include:A review of the facility policy titled ‘Psychotropic Medication Use' with a revision date of 2/25 indicated the following:-Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non pharmacological alternatives, the indications and rationale for the recommendation, the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings and the resident's/representative's right to accept or decline treatment.Resident #129 was admitted to the facility in May 2025 with diagnoses including schizoaffective disorder.Review of Resident #129's most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition.Review of Resident #129's July 2025 physician's orders indicated the following:-Fluphenazine (an antipsychotic medication used to treat schizophrenia and other psychotic disorders) HCI (Hydrochloride) Oral Tablet 5 milligrams (Fluphenazine HCI) Give 1 tablet by mouth in the evening for behavioral management. Start date:7/1/25-Fluphenazine HCI Oral Tablet 5 milligrams (Fluphenazine HCI) Give 2 tablets by mouth in the evening for behavioral management. Start date:7/16/25Review of Resident # 129's July 2025 Medication Administration Record (MAR) indicated that Fluphenazine was administered on 7/2/25, 7/3/25, 7/4/25, 7/5/25, 7/6/25, 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25, 7/12/25, and 7/13/25.Review of the medical record indicated that Resident #129 has a court appointed Guardian. The court also authorized the treatment of Resident #129 with antipsychotic medication. A Roger's treatment plan (a court approved plan authorizing the administration of antipsychotic medication to an individual who is deemed incapacitated and unable to consent to treatment) with the medications and alternative medications Resident #129 could be administered was included.Further review of the Roger's treatment plan with an expiry date of 5/4/26 failed to indicate Fluphenazine as one the antipsychotic medications approved by the court to be used for treatment for Resident #129. The Roger's treatment plan also failed to indicate Fluphenazine as one of the alternative medications listed.During an interview and record review on 7/17/125 at 1:18 P.M., the Regional Social Worker reviewed the medical record and said Resident #129 had been administered Fluphenazine from 7/2/25-7/13/25 as ordered. The Regional Social Worker said Resident #129 should not have been administered Fluphenazine prior to getting legal consent from court.During an interview on 7/18/25 at 10:56 A.M., the Director of Nurses said he expects informed legal consent to be obtained from the responsible party prior to administering antipsychotic medication.During a telephone interview on 7/18/25 at 10:21 A.M., the court appointed Roger's Monitor, (a person appointed by the court to oversee the implementation of a court approved treatment plan for an incapacitated individual), said the [NAME] monitor role is new to him. He said he was made aware by the facility that the Resident was being administered Fluphenazine, but he was not aware that the court needed to give consent because it was not listed on the Treatment plan.

Based on record review and interview, the facility failed to formulate Advance Directives for one Resident #129 out of a sample of 36 Residents. Specifically, the facility failed to expand a Roger's treatment plan, (a court approved plan that outlines the specific medical treatment, particularly antipsychotic medication), prior to administering antipsychotic medication.Findings include:Review of the facility policy titled ‘Advance Directives' with a revision date of September 2022 indicated the following:-The resident has the right to formulate an Advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.-Advance directive is written instruction, such as a living will or durable power of attorney for healthcare, recognized by state law (whether statutory or as recognized by the courts of the state) relating to the provisions of health care when the individual is incapacitated.-Legal representative (i.e. substitute decision maker, proxy agent- a person designated and authorized by an advance directive or state law to make treatment decisions for another person in the event the other person becomes unable to make necessary health care decisions.Resident #129 was admitted to the facility in May 2025 with diagnoses including schizoaffective disorder. Review of Resident #129's most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition.Review of Resident #129's July 2025 physician's orders indicated the following:-Fluphenazine (an antipsychotic medication primarily used to treat schizophrenia and other conditions causing psychosis) HCI (Hydrochloride) Oral Tablet 5 milligrams (Fluphenazine HCI) Give 1 tablet by mouth in the evening for behavioral management. Start date:7/1/25-Fluphenazine HCI Oral Tablet 5 milligrams (Fluphenazine HCI) Give 2 tablets by mouth in the evening for behavioral management. Start date:7/16/25Review of Resident #129's July 2025 Medication Administration Record (MAR) indicated that Fluphenazine was administered on 7/2/25, 7/3/25, 7/4/25, 7/5/25, 7/6/25, 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25, 7/12/25, and 7/13/25.Review of the medical record indicated that Resident #129 has a court appointed Guardian. The court also authorized the treatment of Resident #129 with antipsychotic medication. A Roger's treatment plan with the medications and alternative medications Resident #129 could be administered was included.Further review of the Roger's treatment plan with an expiry date of 5/4/26 failed to indicate Fluphenazine as one the antipsychotic medications approved by the court to be used for treatment for Resident #129. Further review of the Roger's treatment plan failed to indicate Fluphenazine was one of the alternative medications.During an interview and record review on 7/17/125 at 1:18 P.M., the Regional Social Worker reviewed the medical record and said Resident #129 had been administered Fluphenazine from 7/2/25-7/13/25 as ordered. The Regional Social Worker said the Roger's treatment plan should have been expanded in court to include Fluphenazine prior to administering the medication to the Resident.During an interview on 7/18/25 at 10:56 A.M., the Director of Nurses said only medications in the Roger's treatment plans should be administered to residents and if new antipsychotic medications are approved by the physician, the facility should go back to court to expand the Roger's treatment plan to include the new medication.During a telephone interview on 7/18/25 at 10:21 A.M., the court appointed Roger's monitor, (a person appointed by the court to oversee the implementation of a court approved treatment plan for an incapacitated individual), said the [NAME] monitor role is new to him. He said he was made aware by the facility that the Resident was being administered Fluphenazine but he was not aware that the court would need to expand the [NAME] treatment plan to include Fluphenazine.

Based on observation, record review and interview, the facility failed to provide initial and ongoing assessments of a wheelchair seatbelt to ensure one Resident (#24) was free from restraints out of a total sample of 36 residents. Findings include:Review of the facility policy titled, Use of Restraints, dated April 2017, indicated the following: -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical condition and to determine if there are less restrictive interventions that may improve the symptoms. Resident #24 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances, traumatic brain injury, legal blindness and unsteadiness on feet. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status score of 8 out of a possible 15, which indicated the Resident has moderate cognitive impairment. The MDS also indicated Resident #24 requires substantial assistance from staff for all self-care and mobility tasks. On 7/16/2025 at 8:37 A.M., Resident #24 was observed sitting in his/her wheelchair in the unit hallway. The Resident's wheelchair had a seatbelt which was secure around the Resident's waist. When asked, Resident #24 was unable to say how long the seatbelt had been on his/her wheelchair, why it was on the wheelchair or if he/she had sustained any falls while at the facility. Review of Resident #24's physician orders failed to indicate an order for a seatbelt to be on the Resident's wheelchair. Review of Resident #24's care plans failed to indicate an intervention in any of the personalized care plans for the use of a seatbelt on the Resident's wheelchair. Review of Resident #24's medical record failed to indicate a restraint assessment had been completed to determine whether or not the seatbelt was a restraint. During an interview on 7/18/2025 at 10:15 A.M., Unit Manager #2 said Resident #24 uses a seatbelt on his/her wheelchair. Unit Manager #2 said she does not know if the facility ever did a restraint assessment for the seat belt on Resident #24's wheelchair and said she was unsure if a restraint assessment needed to be completed. During an interview on 7/17/2025 at 11:38 A.M., the Director of Nursing said Resident #24 has his/her own personal wheelchair and was admitted with that wheelchair. The Director of Nursing said the wheelchair does have a seatbelt and that the Resident is able to release the belt independently. The Director of Nursing said a formal restraint assessment should have been completed upon admission and should be completed throughout the Resident's stay to ensure the seatbelt is not a restraint. The Director of Nursing said the use of a seatbelt should also be included in Resident #24's care plans.

Based on record review and interview, the facility failed to accurately and timely report an allegation of misappropriation to the State Agency for one Resident (#29) of 36 sampled residents. Specifically, Resident #29 alleged that a staff member stole a piece of jewelry, and the facility did not report the allegation to the State Agency. Findings include: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated as revised September 2022, indicated: -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immedicably to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies. These agencies include the state licensing/certification agency responsible for the surveying /licensing the facility. Immediately is defined as within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #29 was admitted to the facility in June 2025, and has diagnoses which include hypertension, diabetes, depression and anxiety. Review of Resident #29's Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status examination score of 10, signifying moderate cognitive impairment. The Resident was dependent on staff for most activities of daily living. During an interview on 7/16/25 at 9:45 A.M., Resident #29 said that on 7/9/25, during the day shift, a staff member and CNA #5 entered the bedroom to give him/her a bed bath. The Resident said his/her neck chain was removed and placed on the over-bed table, placed directly in front of him/her. Resident #29 said the staff member then swept the chain into a small basin containing water and removed the basin. Resident #29 said he/she told the staff member he/she just saw her steal his/her chain. Resident #29 said the staff member denied taking the chain and told the Resident he/she did not own a chain. Resident #29 said the staff member left the bedroom but later returned and asked the Resident not to report her to management and offered to buy the chain for $50. Resident #29 said that day he/she told CNA #5 that the staff member stole his/her neck chain, and that CNA #5 confirmed to him/her he/she owned a neck chain. Resident #29 said that no one had interviewed him/her about the incident. During an interview on 7/17/25 at 8:33 A.M., CNA #5 said that on 7/16/25 Resident #29 told her that on 7/9/25 a staff member stole his/her chain necklace. CNA #5 said she had seen Resident #29's neck chain before the alleged incident. CNA #5 said she forgot to report the allegation of theft to a nurse or administration. During an interview on 7/17/25 at 9:31 A.M., the surveyor informed the Administrator that Resident #29 told the surveyor a staff member stole a chain necklace from him/her on 7/9/25, dayshift. The Administrator said he was unaware of the allegation but would immediately start an investigation and report the allegation within two hours through the Health Care Facility Reporting System to the State Agency. During an interview on 7/18/2025 at 10:34 AM, Unit Manager (UM) #3 said that she and the Administrator interviewed Resident #29 on 7/17/25. UM #3 said the Resident told them that on 7/9/25 a staff member stole his/her neck chain. UM #3 said the Resident told her he saw the staff member sweep the chain into a small water basin while washing him/her in bed. UM #3 said the Resident told her that he/she confronted the staff member about the alleged theft, and that the staff member denied that the Resident owned a neck chain. UM #3 said the Resident told her that CNA #5 was present during the incident, but that CNA #5 did not take the chain. UM #3 said that she interviewed CNA #5, and that CNA #5 told her she forgot to report the incident because it was a busy day. UM #3 said the staff members who provided bathing care to Resident #29 on 7/9/25 were arriving later this afternoon and would be interviewed for the investigation. Review of HCFRS on 7/18/25 at approximately 9:30 A.M. indicated the Facility had reported Resident #29's allegation of theft as missing personal property. The HCFRS narrative indicated: Today at 9:00am a DPH state surveyor here on annual survey asked the administrator if he was aware of a resident missing necklace. I reported i [sic] have not heard anything and went to interview the resident immediately. Resident states that on 7/9/25 he/she took the chain off and he/she saw one of the aides sweep it into a bucket. He/she cannot remember or identify who the individual was that took the item. Police came in to take a statement.During an interview on 7/18/25 at 10:01 A.M., the Administrator said Resident #29 had told him that a yet unidentified staff member stole his/her chain necklace. The Administrator said he reported the incident as missing personal property because he did not understand that allegations of theft should be reported as misappropriation. The Administrator said he would resubmit the allegation of misappropriation through HCFRS. On 7/21/25 at approximately 7:10 A.M., the surveyor reviewed the Health Care Facility Reporting System (HCFRS). The facility's HFRS reports indicated that as of this time the facility had not revised its original report of missing personal property and still had not reported Resident #29's allegation of theft to the State Agency, (four days after the facility had been made aware of the allegation.)

Based on record review and interview, the facility failed to develop a plan of care for monitoring the effects of psychotropic medications for one Resident (#179) out of a total sample of 36 residents. Findings include:Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated March 2022, indicated the following: Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.Resident #179 was admitted to the facility in July 2025 with diagnoses including major depression and unspecified psychosis.Review of the Brief Interview for Mental Status (BIMS) completed on 7/16/25, indicated the Resident had a score of 8 out of a possible 15, which indicated the Resident has moderate cognitive impairment. Review of Resident #179's physician orders indicate the following orders for psychotropic medications:-Risperidone (an antipsychotic medication) tablet 0.25 MG (milligrams). Give 1 tablet by mouth at bedtime for rehab.-Trazodone (a mood stabilizing medication) Oral Tablet 50 MG. Give 1 tablet by mouth every 24 hours as needed for insomnia until 7/26/2025.The physician orders failed to indicate an order to ensure monitoring of the medications for side effects.Review of Resident #179's individualized care plans failed to indicate a care plan was developed for the use of psychotropic medications.During an interview on 7/18/2025 at 8:04 A.M., Nurse #8 said she is not sure who develops resident care plans at the facility as she has never written one. During an interview on 7/18/2025 at 10:15 A.M., Unit Manager #2 said the admitting nurse creates the baseline care plans and then the interdisciplinary team edits and creates all other needed care plans to address all needs of the residents. Unit Manager #2 said residents who are receiving psychotropic medications should have a care plan created to monitor the side effects of these types of medications. Unit Manager #2 reviewed Resident #179's care plans and said Resident #179 should have had a psychotropic medication care plan developed and didn't. Unit Manager #2 said there should also be an order to monitor the side effects of psychotropic medications and this was not done.During an interview on 7/18/2025 at 10:57 A.M., the Assistant Director of Nursing said all residents who are receiving psychotropic medications should be monitored for potential side effects. The Assistant Director of Nursing said this monitoring is ensured by either having an order to monitor or having a care plan for monitoring in place. The Assistant Director of Nursing reviews Resident #179's medical record with the surveyor and said the Resident was missing psychotropic care plans and an order to monitor potential side effects of these medications.During an interview on 7/18/25 at 12:14 P.M., the Director of Nursing said any resident receiving psychotropic medications should have a care plan addressing the use of these medications and the need to monitor for potential side effects of these medications.

Based on observation, record review and interview the facility failed to provide quality standards of professional practice for 3 residents (# 11 , #15 and #21), out of a total sample of 36 residents. Specifically:1.For Resident #11, the facility failed to implement physician's orders by administering liquid consistency as ordered.2. For Resident #15, the facility failed to implement the use of a Prevlon Boot (a specialty device utilized to prevent pressure on the heel) as ordered by the physician.3. For Resident #21 the facility failed to adhere to professional standards of nursing practice, when Nurse #2 left medications with Resident #21, who was not assessed as being able to self-administer medications. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #11 was admitted to the facility in February 2025 with diagnoses including dysphagia. Review of Resident #11's most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the resident is rarely/never understood. Review of Resident #11’s July 2025 physician’s orders indicated the following: -Regular diet, pureed (PU4) texture, moderately thick (MO3) consistency. Start date:5/30/25. [sic] -Aspiration precaution every shift. Start date: 5/19/25. -Aspirin EC (enteric coated) Tablet Delayed Release 325 milligrams-Give 1 tablet by mouth in the morning for ppx (prophylaxis), take with a full glass of water, do not crush. Give with food to minimize GI (gastrointestinal) irritation. Start date: 6/4/25. Review of Resident #11’s most recent speech therapy treatment encounter notes dated 6/17/25 indicated the following: Precautions-PEG (Percutaneous Endoscopic Gastronomy) continuous nocturnal feeds starting at 7 PM, pureed solids, moderately thick, (honey), liquids. Feeding assistance, Aspiration precautions. During an interview on 7/18/25 at 7:57 A.M., Nurse #6 said she had just administered Aspirin to Resident #11. She said she let the Aspirin dissolve in apple sauce (a puree of stewed apples) prior to administering it to the Resident. Nurse #6 said after Resident #11 took the dissolved Aspirin in apple sauce, she administered Apple juice (a drink made by pressing and processing apples) because Resident #11 does not like water. Nurse #6 said she did not add any thickening agent to the Apple juice. Review of the July 2025 Medication Administration Record (MAR) indicated Aspirin had been administered as ordered. The MAR further indicated Nurse #6 had administered Aspirin to Resident #11 on the following days, 7/11/25, 7/12/25, 7/15/25, 7/16/25 and 7/18/25. During an interview on 7/18/25 at 8:42 A.M., the Speech Therapist said Resident #11 should only ingest moderately thick liquids. The Speech Therapist said Nurse #6 should have thickened the Apple juice prior to administering it to the Resident. During an interview on 7/18/25 at 10:59 A.M., the Director of Nurses said Nurses should implement physician’s orders. The DON said Resident #11 should not be administered thin liquids. The DON said the Nurses should thicken liquids prior to administering the liquids to Resident #11. 2. Resident #15 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease and type 2 diabetes. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #15 is severely cognitively impaired and is dependent on staff for assistance with bathing, dressing and eating. Resident #15 was unable to participate in the interview process due to his/her cognitive status. Review of the clinical record indicated a physician’s order: Prevalon boot to RLE (right lower extremity) at all times as tolerated. May remove for care and to assess for skin integrity, every shift, 5/9/24. On 7/16/2025 at 7:56 A.M., the surveyor observed a Prevalon boot on Resident #15’s bedside table. Resident #15 was asleep in his/her wheelchair not wearing the Prevalon Boot. On 7/16/2025 at 12:54 P.M., the surveyor observed Resident #15 eating lunch in the dining room. He/she was not wearing the Prevalon boot. On 7/17/2025 at 8:14 A.M., the surveyor observed Resident #15 seated in his/her wheelchair watching TV in his/her room. He/she was not wearing the Prevalon boot. On 7/17/2025 at 9:08A.M. the surveyor observed Resident #15 in the dining room eating breakfast. He/she was not wearing the Prevalon boot. On 7/17/2025 at 10:40 A.M., the surveyor observed Resident #15 in an activity. He/she was not wearing the Prevalon boot. Review of the Resident #15’s care plans failed to indicate Resident #15 had behaviors of refusing care. Review of the nurse progress notes failed to indicate Resident #15 had refused wearing the Prevlon boot on 7/16/25 and 7/17/25. Review of the July 2025 Treatment Administration Record (TAR) indicated Resident #15 had been wearing his/her Prevlon boot during the 7:00 A.M., – 3:00 P.M. shift; contrary to the surveyor's observations. During an interview on 7/17/2025 at 10:42 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #15 is easy going and never refuses care. During interviews on 7/17/25 at 12:18 P.M., and 7/17/25 at 1:57 P.M., Nurse #1 said that the Resident does not refuse care or treatments. Nurse #1 said that CNAs are responsible for donning Prevlon boots on residents and the nurses verify they are put on. Nurse #1 said she thought Resident #15’s Prevlon boot was put on him/her around breakfast time and was not aware that he/she had not been wearing it. During an interview on 7/18/2025 at 10:18 A.M., the Assistant Director 0f Nursing (ADON) said that physician's orders should be implemented as ordered. The Director of Nursing (DON) said that CNAs should be donning Prevlon boots and nurses are expected to verify and document that residents are wearing the boots as ordered. 3. Resident #21 was admitted to the facility in August 2019 with diagnoses that include but are not limited to end stage renal disease, dependence on renal dialysis, unspecified protein-calorie malnutrition, major depressive disorder, and adult failure to thrive. Review of the facility’s policy, titled Administering Medications dated with a revision date April 2019, indicated the following: Medications are administered in a safe and timely manner and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the comprehensive Minimum Data Set assessment dated [DATE] indicated Resident #21 scored 15 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as cognitively intact, and requires supervision or touching assistance with daily care activities including toileting, dressing and transfers. During an interview on 7/16/25 at 8:04 A.M., Resident #21 was sitting in his/her wheelchair. A medication cup with pills in a substance and a spoon was on the overbed tray table. Resident #21 picked up the medication cup and moved the spoon around revealing partially disintegrated pills. Resident #21 said he/she did not know what the pills were and that the nurse left them because he/she was getting dressed this morning. Review of Resident #21’s medical record failed to reveal a physician order, a self-administration of medication assessment, or care plan indicating medication could be left with Resident #21 for self-administration. During an interview on 7/16/2025 at 8:26 A.M., Nurse #2 said a nurse’s duty is to make sure residents take their medication as ordered and to stay with the resident when they take their medication, or document if they refuse to take the medication. Nurse #2 said that medication should not be left with a resident. Nurse #2 said Resident #21 is independent and knows his/her medications. Nurse #2 and the surveyor went to Resident #21’s room and the medication cup with pills inside the cup was on the overbed tray. Nurse #2 said he gave Resident #21 the medications whole in apple sauce. Nurse #2 said it may be protonix (a medication used to treat acid reflux), and lamictal (a mood stabilizer). Nurse #2 said the medication should not have been left in Resident #21’s room. During an interview on 7/18/2025 at 10:37 A.M., Nurse #5 said when a nurse administers medication it is the nurse’s duty to stay with the resident while they take their medication and that medication in a medication cup is not left with a resident. Nurse #5 said Resident #21 accepts his/her medications and the medication in a cup should not have been left in the room with the Resident. During an interview on 7/18/2025 at 10:48 A.M., Unit Manager #3 said the nurse administering medication stays with a resident to ensure the medication is taken and does not leave medication in a resident’s room unless they have a physician’s order for self-administration. During an interview on 7/18/2025 at 11:06 A.M., the Director of Nursing (DON) said unless a resident has an order and care plan for self-administration of medication the nurse is to stay with the resident to ensure the medication was taken and the medication cup containing medication should not be left with the resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of diabetes mellitus, Peripheral Vascular Disease (PVD), and peripheral neuropathy, the facility failed to ensure foot care, including toenail care, was provided in a timely manner once requested.Findings include:Review of the Facility Policy titled Foot Care, dated as last revised 10/2022, indicated residents are provided with foot care and treatment to maintain mobility and foot health.The Policy indicated the following;-Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (diabetes, peripheral vascular disease, immobility, etc.);-Residents are assisted with making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc.) as needed; and-Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include corns, neuroma, calluses, hallux valgus (bunions), digiti flexus (hammertoe), heel spurs, and nail disorders.Resident #1 was admitted to the Facility in March 2023, diagnoses include diabetes mellitus, peripheral vascular disease, diabetic neuropathy, and a history of a right below the knee amputation.Review of Resident #1's Document of Resident Incapacity Form dated 05/31/23, indicated his/her Health Care Proxy (HCP) had been activated.During a telephone interview on 07/14/25 at 2:56 P.M., Resident #1's Health Care Agent (HCA) said that he/she was a diabetic and that starting around 09/2024, along with his/her palliative care Nurse Practitioner (NP), had requested that he/she be seen by a podiatrist to cut his/her toenails.The HCA said that it took months before a Podiatrist treated Resident #1's toenails despite multiple requests over several months.Review of Resident #1's Physician's Orders, dated 08/27/24, indicated to consult Podiatry Care as needed.Review of Resident #1's Palliative Care Initial Visit Communication Form, written by the Nurse Practitioner, (NP), dated 09/18/24, indicated a recommendation to add Resident #1 to the facility's podiatry list. Review of Resident #1's Palliative Care Follow-up Form written by the NP, dated 10/23/24, indicated that he/she was still in need of podiatry and again recommended to add Resident #1 to the podiatry list.Review of Resident #1's Palliative Care Follow-up Form written by the NP, dated 11/07/24, indicated that he/she was still in need of podiatry and again recommended to add Resident #1 to the podiatry list.Review of Resident #1's Palliative Care Follow-up Form written by the NP, dated 01/08/25, indicated that his/her toenails were long, he/she had not yet been seen by a podiatrist and again recommended to place Resident #1 on the podiatrist list.During a telephone interview on 07/17/25 at 11:50 A.M., The Customer Care Specialist for the Facility's Podiatry Care, said that a Podiatrist visits the Facility on a quarterly basis and a podiatrist had been in the Facility for residents requiring routine podiatry foot care on 10/07/24, 12/26/24, and 02/28/25.Review of Resident #1's medical record indicated that there was no documentation to support that he/she had been referred to or had been seen the Podiatrist, despite being in the Facility on 10/07/24 and 12/26/24 for service to other residents.Review of Resident #1's consent to receive a Podiatry Consult via a third-party vendor was dated and signed 01/08/25 by his/her Health Care Agent (HCA).Review of Resident #1's Podiatry Visit Note, dated 02/28/25, indicated he/she had an initial exam and treatment for foot care.The Note further indicated Resident #1's left foot toenails were;-Elongated (long in relation to width, especially unusually so);-Dystrophic (abnormal changes in texture, growth, color, or shape of toenails);-Discolored;-Mycotic (caused by or related to fungus);-Thick;-Yellow;-Lytic (separation of the nail plate from the nail bed; and-Nail thickness of nine (9) millimeters (mm) for great left toe, and four (4) mm for all other toenails and all toenails required debridement (average nail toenail thickness for men is 1.65 mm).During a telephone interview on 07/22/25 at 11:32 A.M., the Palliative Care Nurse Practitioner (NP) said that she does not know why Resident #1 was not seen in a timely manner and said she had requested via recommendations in her visit notes, to have Resident #1 added to the Facility Podiatry list multiple months in a row.During an interview on 07/15/25 at 01:14 P.M., the Assistant Director of Nurses (ADON), said that she was not aware that the NP recommended that Resident #1 been placed on the list to be seen by the Podiatrist.The ADON said that the Podiatrist rounds at the facility on a quarterly schedule and was in the Facility on 10/07/24 and 12/26/24.During an interview on 07/15/25 at 4:06 P.M., the Director of Nurses (DON) said that he was not aware Resident #1 required footcare from the Facility Podiatrist.The DON said that the Facility's expectation is that upon admission, all residents and/or their activated HCA, are to be educated by nursing staff on the consent for receiving additional services such as podiatry, audiology, and vision.The DON said when a request or recommendation is made by the resident, HCA, or provider to be seen by a vendor, the nursing staff is to add the resident's name to the appropriate list.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data Set (MDS) assessment. Findings include: Review of the Facility Policy titled Comprehensive Person-Centered Care Plans, dated as last revised 03/2022, indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The Policy further indicated that the IDT reviews and revises the care plan; -When there has been a significant change in the resident's condition; -When a desired outcome is not met; -When a resident has been readmitted to the facility; and -At least quarterly, in conjunction with the quarterly MDS. Resident #1 was admitted to the Facility in November 2024, diagnoses included metastatic Anaplastic Thyroid Cancer (ATC, a rare and aggressive form of thyroid cancer that grows and spreads rapidly, often within weeks)requiring a tracheostomy tube (tube inserted through the trachea, allowing one to breath) and gastrostomy tube (tube inserted into the stomach that provides nutrition), chronic pulmonary (lung) embolism (blood clot) to right lower lung, and Deep Vein Thrombosis (DVT, blood clot) to right arm. Review of Resident #1's MDS Schedule indicated that a Quarterly MDS had been completed with an Assessment Reference Date (ARD) of 02/25/25. Further review of Resident #1's MDS Schedule indicated he/she had multiple hospitalizations with readmission back to the facility on [DATE], 04/22/25, 05/01/25, and 05/08/25. However, review of the Resident #1's Comprehensive Care Plan, dated as initiated 11/11/2024, indicated there was no documentation to support the comprehensive care plan had been reviewed or revised after the completion of the 02/25/25 MDS. Review of Resident #1's Medical Record indicated that there was no documentation to support that the IDT reviewed or revised his/her comprehensive care plan throughout his/her six (6) month stay. During a telephone interview on 05/29/25 at 12:45 P.M., Minimum Data Set (MDS) Nurse #1 said she was not aware that Resident #1's care plan had never been revised or reviewed by the IDT team. MDS Nurse #1 said that each discipline is responsible for reviewing and revising their own care plans prior to the scheduled care plan meeting with the resident and family. MDS Nurse #1 said care plans are to be reviewed and revised after each comprehensive MDS is completed and upon readmission from the hospital. During a telephone interview on 05/29/25 at 12:57 P.M., MDS Nurse #2 said that he was not aware that Resident #1's care plan had not been reviewed or revised after his/her comprehensive MDS had been completed. MDS Nurse #2 said that comprehensive care plans are reviewed and revised upon admission, quarterly, with a significant change, and upon readmission by the IDT prior to the actual care plan meeting is conducted. During an interview on 05/20/25 at 3:55 P.M., the Director of Nurses (DON) said that he was not aware that Resident #1's care plans had not been reviewed or revised throughout his/her stay. The DON said that it is the Facility's expectation that all comprehensive care plan be reviewed and revised according to the Facility Policy, including upon admission, quarterly, with a significant change assessment and when a resident is readmitted from a medical leave of absence.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had an allergy to shellfish, the facility failed to ensure his/her environment was free of hazards, when on 09/12/24, Resident #1 was served a meal that consisted of seafood (which included shrimp), Resident #1 consumed the meal, developed signs and symptoms of an allergic reaction, including shortness of breath (SOB), puffy watery eyes and flushed appearance, he/she developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called, and Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment. Findings Include: Review of the Facility's Policy tilted Food Allergies and Intolerances, dated as revised August 2017, indicated the following: -residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional values; steps are taken to prevent resident exposure to the allergen(s) -food allergies are immune system responses to allergens (foods) -severe food allergies are noted on the face of the chart indicating severe food allergy: (name of food) and communicated in writing directly to the dietician and the director of food and nutrition services -meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur -residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat -nursing staff and food service employees are trained in the signs and symptoms of allergic reactions to foods and basic first aid measures in the event of a food allergy emergency -the attending physician will be notified of the resident's food allergies and orders for emergency medications (e.g., epinephrine, antihistamines) and emergency interventions will be documented Review of the Facility's Policy tilted Tray Identification, dated as revised April 2007, indicated the following: -appropriate identification/coding shall be used to identify various diets -to assist in setting up and serving the correct food trays/diets to resident, the Food Services Department will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets -the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas -nursing staff shall check each food tray for the correct diet before serving the residents -if there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served Resident #1 was admitted to the Facility in September 2024, diagnoses included hyperlipidemia (high cholesterol), depression, hypertension, mild intermittent asthma, and cardiac murmur (whooshing or rasping sound during a heartbeat). Review of Resident #1's Allergy Report, dated 09/06/24, indicated he/she had the following allergies: shellfish (e.g., shrimp, crabs, lobster, oysters, scallops, and snails), Zoloft (antidepressant) cat/dog dander, iodine and pollen extract. Review of Resident #1's Admission Assessment for Mental Status, dated 09/09/24, indicated that he/she was alert, oriented and able to make his/her own health care decisions. Review of Resident #1's Nutrition Evaluation, dated 09/10/24, indicated that he/she had the following allergies: shell fish, iodine, Zoloft, cat/dog dander and pollen extract. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/14/24, indicated that on 09/12/24, Resident #1 suffered an allergic reaction when he/she ingested shrimp for dinner. The Report indicated that Resident #1 reported shortness of breath (SOB), puffy eyes, his/her Physician was notified and ordered to administer an Epinephrine (Adrenaline, hormone, medication used for emergency treatment of severe life threatening allergic reactions) injection, Prednisone (corticosteroid), and Benadryl (antihistamine) stat (immediately) (which was administered by the Nursing Supervisor) and to monitor Resident #1. The Report indicated that Resident #1 developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called and he/she was transported to the Hospital Emergency Department for evaluation. The Report further indicated that Resident #1 had an allergy to shellfish, and he/she was served seafood that he/she was allergic to. Review of Resident #1's Hospital Discharge Summary, dated 09/16/24, indicated that Resident #1 presented (on 9/12/24) with anaphylaxis (severe, potentially life threatening allergic reaction) due to shrimp exposure (shellfish allergy) and he/she received an EpiPen (epinephrine) injection, Prednisone 60 milligrams (mg) and Benadryl 50 mg in the field. The Summary indicated upon his/her arrival to the emergency room , he/she was tachycardic (fast heart rate over 100 beats a minute) requiring 6 Liters (L) of oxygen, and he/she was treated with additional Epinephrine 0.3 mg, Pepcid 20 mg, and Solumedrol (corticosteroid) 80 mg. The Summary further indicated Resident #1 reported that he/she was eating dinner which included shrimp, causing him/her to have a sudden, severe onset of difficulty breathing and he/she experienced a tightening sensation in his/her throat. During an interview on 10/09/24 at 12:36 P.M., Resident #1 said at dinner time (exact date unknown) someone had given him/her food that had shrimp on it and said he/she ate the shrimp because that is what he/she was given. Resident #1 said shortly after eating the shrimp, he/she could not breathe and was gasping for air. Resident #1 said he/she put his/her call light on, one of the Certified Nurse Aides (CNA's) came to his/her room, he/she told her that he/she did not feel good and was having trouble breathing. Resident #1 said it was because he/she was having an allergic reaction to the shrimp. Resident #1 said it was awful and said he/she only remembered hearing someone say we are going to use an EpiPen on you. Review of the Facility's Dietary Menu, dated 09/12/24, indicated the following two meals were on the menu to be served for dinner: -Pasta and Krab Salad Plate and Chefs Breadbasket -Italian Sub Sandwich with Pasta Salad However, further review of the Facility's Dietary Substitution List, indicated that on 09/12/24, Seafood [NAME] was substituted for the Krab and Pasta Salad dinner meal. During an interview on 10/09/24 at 1:44 P.M., the Assistant Food Service Director (AFSD) said on 09/12/24 Seafood [NAME] was substituted for the pasta and Krab salad dinner meal. The AFSD said Seafood [NAME] consisted of crab, shrimp, and fish in a white cream sauce over pasta. Review of Resident #1's Nurse Progress Note, dated 09/12/24, (written by Nursing Supervisor), indicated that Resident #1 presented with acute shortness of breath (SOB), puffy watery eyes and he/she was flushed appearing with acute hypoxia (low level of oxygen in the blood). The Note indicated there was a suspicion Resident #1 had an allergy to shrimp (per him/her) and he/she was given an EpiPen injection, along with 60 mg of Prednisone and Benadryl. The Note indicated Resident #1 was observed having stridor with deteriorating breathing, 911 was called, and he/she was transferred to the Hospital Emergency Department (ED). During an interview on 10/10/24 at 12:18 P.M., (which included review of her written witness statement), Certified Nurse Aide (CNA) #1 said on 09/12/24 at dinner time Nurse #1 checked Resident #1's meal tray to make sure the food was appropriate and handed it to her. CNA #1 said she brought Resident #1's meal tray to him/her, set up his/her meal and left the room. CNA #1 said Resident #1's meal was pasta with white sauce, but said she did not know and could remember if there was seafood (shrimp) on top of the pasta. CNA #1 said about 45 minutes later Resident #1 put his/her call light on, she went to answer it and Resident #1 told her he/she did not feel good and to call the nurse please. CNA #1 said she told Nurse #1 right away that Resident #1 was not feeling good. During an interview on 10/10/24 at 11:27 A.M., (which included review of her written witness statement), Nurse #1 said the nurses check all resident's meal trays for correct diet order and any allergies before they are given to a resident. Nurse #1 said when she checked Resident #1's meal tray there was pasta with a white gravy sauce. Nurse #1 said she did not remember what other food was on the pasta, said it was not meat (beef) and that she could not recall seeing any seafood. Nurse #1 said after checking Resident #1's meal tray she put his/her tray back into the food truck. Nurse #1 said about 45 minutes later CNA #1 told her that Resident #1 was having trouble breathing and she immediately went to his/her room. Nurse #1 said Resident #1 was SOB, was having trouble breathing and she informed the Nursing Supervisor. Nurse #1 said she was not aware that Resident #1 had a shellfish allergy because when she checked his/her meal tray, that she had not looked at his/her diet slip for allergies, but said she should have. Review of Resident #1's Dinner meal diet slip, dated 09/12/24, indicated that he/she had an allergy to shellfish. During an interview on 10/09/24 at 2:10 P.M., the Nursing Supervisor said Nurse #1 informed him that Resident #1 complained of being SOB and he immediately went to Resident #1's room. The Supervisor said Resident #1's face looked puffy, flushed and his/her eyes were watery and that it looked like he/she was having an allergic reaction to something. The Supervisor said he asked Resident #1 if he/she was allergic to anything and said Resident #1 told him that he/she was allergic to shrimp and might have eaten some. The Supervisor said he notified Resident #1's Physician and received orders to administer an EpiPen injection, Prednisone, and Benadryl STAT and continue to monitor Resident #1 for stridor. The Supervisor said after administering the medications, Resident #1 continued to be monitored, his/her breathing becoming worse, and that he/she developed stridor. The Supervisor said 911 was called and Resident #1 was transferred to the Hospital ED for evaluation. During a telephone interview on 10/15/24 at 12:34 P.M., the Director of Nursing (DON) said upon admission to the Facility, they were aware that Resident #1 had an allergy to shellfish. The DON said she was notified on 09/12/24 that Resident #1 was sent to the Hospital due to possibly being exposed to seafood. The DON said she did an investigation and said Resident #1 had been exposed to shellfish, that she was not sure how it happened, but added that the kitchen must have sent the wrong meal tray. The DON said she expected all nurses to check residents' meal trays, compare it with the resident's diet order slip and allergies listed on a resident meal slip to ensure that residents are receiving the correct meal, prior to receiving their tray. The DON said if a resident's diet slip does not match what is on the meal tray, the tray should be removed immediately from the food truck and the nurse should call the kitchen to request a meal tray with an appropriate meal for the resident. On 09/16/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 09/16/24, Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary). B. On 09/16/24, the Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl. C. On 09/12/24 and 09/13/24, the Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physicians' and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present. D. On 09/13/24 and 09/16/24, the Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy. E. All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine. F. The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed. G. The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month. H. The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved. I. The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had an allergy to shellfish, the Facility failed to ensure meals prepared and served to him/her accommodated his/her food allergy, when on 09/12/24, dietary staff preparing his/her dinner time meal tray put a meal that included shellfish (shrimp) on it, Resident #1 complained of not feeling well, said he/she had difficulty breathing, 911 was called and he/she was transported to the Hospital Emergency Department (ED), for evaluation and treatment of anaphylaxis (a severe, potentially life-threatening allergic reaction) and he/she was admitted . Findings Include: Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: -each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs -food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident -if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Review of the Facility's Policy tilted Tray Identification, dated as revised April 2007, indicated the following: -appropriate identification/coding shall be used to identify various diets -to assist in setting up and serving the correct food trays/diets to resident, the Food Services Department will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets -the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas -nursing staff shall check each food tray for the correct diet before serving the residents -if there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served Resident #1 was admitted to the Facility in September 2024, diagnoses included hyperlipidemia (high cholesterol), depression, hypertension, mild intermittent asthma, and cardiac murmur (whooshing or rasping sound during a heartbeat). Review of Resident #1's Allergy Report, dated 09/06/24, indicated he/she had the following allergies: shellfish (e.g., shrimp, crabs, lobster, oysters, scallops, and snails), Zoloft (antidepressant), cat/dog dander, iodine, and pollen extract. Review of Resident #1's Nutrition Evaluation, dated 09/10/24, indicated that he/she had the following allergies: shell fish, iodine, Zoloft, cat/dog dander and pollen extract. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/14/24, indicated that on 09/12/24, Resident #1 suffered an allergic reaction when he/she ingested shrimp for dinner. The Report indicated that Resident #1 reported shortness of breath (SOB), puffy eyes, his/her Physician was notified and ordered to administer an Epinephrine (hormone, treats severe life threatening allergic reactions) injection, Prednisone (corticosteroid), and Benadryl (antihistamine) stat (immediately) (which was administered by the Nursing Supervisor) and to monitor Resident #1. The Report indicated that Resident #1 developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called and he/she was transported to the Hospital Emergency Department for evaluation. During an interview on 10/09/24 at 12:36 P.M., Resident #1 said at dinner time someone had given him/her food that had shrimp on it (exact date unknown) and said he/she ate the shrimp because that is what he/she was given. Resident #1 said shortly after eating the shrimp, he/she could not breathe and was gasping for air. Resident #1 said he/she put his/her call light on, one of the CNA's came to his/her room, he/she told her that he/she did not feel good and was having trouble breathing. Resident #1 said that was because he/she was having an allergic reaction to the shrimp. Resident #1 said it was awful and said he/she only remembered was hearing someone say, we are going to use an EpiPen on you. Review of the Facility's Dietary Menu, dated 09/12/24, indicated the following two meals were on the menu to be served for dinner: -Pasta and Krab Salad Plate and Chefs Breadbasket -Italian Sub Sandwich with Pasta Salad However, further review of the Facility's Dietary Substitution List, indicated that on 09/12/24, Seafood [NAME] was substituted for the Krab and Pasta Salad dinner meal. During an interview on 10/09/24 at 1:44 P.M., the Assistant Food Service Director (AFSD) said on 09/12/24 Seafood [NAME] was substituted for the Pasta and Krab salad dinner meal. The AFSD said Seafood [NAME] consisted of crab, shrimp, and fish in a white cream sauce over pasta. Review of Resident #1's Dinner meal diet slip, dated 09/12/24, indicated that he/she had an allergy to shellfish. During an interview on 10/10/24 at 10:07 A.M., Dietary Aide #2 said he worked 4:00 P.M. to 8:00 P.M. on 09/12/24 and called out all residents dinner diet orders to the Cook. Dietary Aide #2 said when he does the calling out in the tray line, he reads the residents diet order and any allergies off to the [NAME] and said the [NAME] then puts the food on the plate, the plate is then placed on the resident's tray and put into the food truck. Dietary Aide #2 said he could not remember anything about a resident receiving the wrong meal that day. During an interview on 10/10/24 at 1:51 P.M., the [NAME] said there is a tray line and one of the Dietary Aides is the caller. The [NAME] said the caller reads the diet slip (which includes the resident's diet and any allergies) to the cook who then puts the meal on the plate, the caller then takes the plate, places it on the resident's tray and into the food truck. The [NAME] said the dinner menu on 09/12/24 was Pasta and Krab Salad but it was substituted with Seafood [NAME] which comes pre-made with crabmeat, shrimp, and scallops in a white cream sauce, that was then put on top of the pasta. The [NAME] said that he did not put any fish in the [NAME] that night. The [NAME] said Dietary Aide #2 called out the resident's dinner diet slips to him on 09/12/24. The [NAME] said he really did not know how Resident #1 received the wrong meal, but it happened and said that most likely the caller (Dietary Aide #2) did not call out his/her allergies to him (the Cook) that night. The [NAME] said he relies on the Dietary Aide that is calling out the resident's diet slips because he cannot see what is on the diet slips when he is preparing the meal. During an interview on 10/09/24 at 11:52 A.M., the Food Service Director (FSD) said all diet slips indicate a resident's diet order, allergies, and dislikes. The FSD said a Dietary Aide calls out the resident's diet and any allergies to the Cook, the [NAME] prepares the meal plate, and the plate is handed to the caller (Dietary Aide) who is then supposed to verify the resident's diet, cover the meal and it is placed on the food truck. The FSD said he expects all dietary staff to follow proper procedure for calling and preparing the correct meal tray (according to dietary orders and allergies) for all residents before the plated meal is placed on their trays and into the food truck. During an interview on 10/10/24 at 11:27 A.M., (which included review of her written witness statement), Nurse #1 said nurses check all resident's meal trays for correct diet order and any allergies before they are given to a resident. Nurse #1 said when she checked Resident #1's meal tray there was pasta with a white gravy sauce. Nurse #1 she did not remember what other food was on the pasta, but said it was not meat (beef) and that she could not recall seeing any seafood. Nurse #1 said after checking Resident #1's meal tray she put his/her tray back into the food truck. Nurse #1 said about 45 minutes later CNA #1 told her that Resident #1 was having trouble breathing and she immediately went to his/her room. Nurse #1 said Resident #1 was SOB, was having trouble breathing and she informed the Nursing Supervisor. Nurse #1 said she was not aware that Resident #1 had a shellfish allergy because when she checked his/her meal tray she had not looked at his/her diet slip for allergies, but said she should have. Review of Resident #1's Hospital Discharge Summary, dated 09/16/24, indicated that (on 9/12/24) Resident #1 presented with anaphylaxis (a severe, potentially life-threatening allergic reaction) due to shrimp exposure (shellfish allergy) and he/she received EpiPen injection, Prednisone 60 milligrams (mg) and Benadryl 50 mg, in the field. The Summary indicated upon his/her arrival to the emergency room , Resident #1 was tachycardic requiring 6 Liters (L) of oxygen, and he/she was treated with additional Epinephrine 0.3 mg, Pepcid 20 mg, and Solumedrol (corticosteroid) 80 mg. The Summary further indicated Resident #1 reported that he/she was eating dinner which included shrimp, causing him/her to have a sudden, severe onset of difficulty breathing and he/she experienced a tightening sensation in his/her throat. During a telephone interview on 10/15/24 at 12:34 P.M., the Director of Nursing (DON) said Resident #1 had an allergy to shellfish and she was notified on 09/12/24 that Resident #1 was sent to the Hospital due to possibly being exposed to seafood. The DON said she did an investigation and said Resident #1 had been exposed to shellfish, was not sure how it happened, but that the kitchen must have sent the wrong meal tray. On 09/16/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 09/16/24, Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary). B. On 09/16/24, the Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl. C. On 09/12/24 and 09/13/24, the Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physician and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present. D. On 09/13/24 and 09/16/24, the Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy. E. All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine. F. The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed. G. The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month. H. The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved. I. The Director of Nurses and/or designee are responsible for overall compliance.

Based on observation, record review and interview, the facility failed to 1. provide adequate supervision and interventions related to falls resulting in falls with injury for two Residents (#60 and #76) and 2. failed to develop and implement an elopement care plan resulting in elopement for one Resident (#103) out of a total of sample of 33 residents. Findings include: 1. For Resident #60, the facility failed to provide adequate supervision during ambulation. Resident #60 fell while ambulating independently and sustained a hip fracture requiring surgery and head laceration requiring sutures. Resident #60 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, repeated falls and schizoaffective disorder. Review of the most recent Minimum Data Set assessment, dated 4/22/23, indicated Resident #60 is severely cognitively impaired and requires assistance with bathing, dressing and ambulation. Review of Resident #60's clinical record indicated he/she resided on the [NAME] unit from January 2023 through April 2023. Review of Resident #60's fall risk assessment, dated 2/10/23, indicated Resident #60 was at high risk of falls and had 3 or more falls in the past 3 months. Review of Resident #60's care plans indicated the following: Focus: Activities of Daily Living, 2/8/23 Interventions: Ambulate continual supervision to assist of 1-2. Transfers, continual supervision to assist. Focus: At risk for falls due to history of falls, unsteady gait, 2/8/23 Interventions: Provide assistance to transfer and ambulate as needed. Encourage to transfer and change positions slowly. Bed alarm. Chair alarm. Review of the Physical Therapy Discharge Summary for dates of service 4/4/23 - 4/6/23 indicated that Resident #60 utilized a four-prong cane inappropriately and required continual supervision or touching assistance for ambulation. Review of Resident #60's fall investigation indicated that on 4/10/23 at 12:04 P.M., Resident #60 had an unwitnessed fall in the hallway. The incident report included written statements which indicated Resident #60 had been seen by staff ambulating in the hallway independently and dragging his/her cane behind him/her prior to the fall. Resident #60 was sent to the hospital where he/she was diagnosed with a hip fracture requiring surgical intervention and a laceration to his/her forehead requiring sutures. The incident report failed to indicate whether Resident #60's care planned alarms were in use at that time of the fall or sounding. During an interview with Nurse #3 on 6/1/23 at 1:51 P.M., she said that she had seen Resident #60 walking alone down the hallway of the nursing unit before he/she fell . Nurse #3 said that Resident #60 was independent with ambulation when he/she resided on the [NAME] unit (which contradicted his/her care plan). During an interview with the Director of Nursing (DON) and the Administrator on 6/1/23 at 12:25 P.M., the DON said that when Resident #60 resided on the [NAME] Unit, he/she would ambulate independently on the unit. The Administrator and the DON agreed that Resident #60's care plans indicated he/she required supervision during ambulation, transfers and also alarms to alert staff if Resident #60 was getting up out of bed or his/her chair. 2. For Resident #76, the facility failed to implement effective interventions related to falls resulting in a fall with injury. Review of the facility's policy titled Assessing Falls and their Causes, dated March 2018, indicated: * When a resident falls, the following information should be recorded: Appropriate interventions taken to prevent future falls. Resident #76 was admitted in April 2023 with diagnoses including Alzheimer's disease and dysphagia. Review of Resident #76's most recent Minimum Data Set assessment, dated 4/8/23, indicated Resident #76 is severely cognitively impaired and requires assistance with bathing, dressing and ambulation. During an observation on 5/30/23 at 11:38 A.M., the surveyor observed Resident #76 self-propelling in his/her wheelchair with a chair alarm in place. Review of Resident #76's clinical record indicated his/her health care proxy was activated by the physician on 4/12/23, indicating he/she was not his/her own decision maker. Review of Resident #76's care plans indicated the following: Focus: Cognitive Loss, initiated 4/2/23 Interventions: Provide cuing and prompting for such things as activities person care or room location. Focus: At risk for falls due to impaired balance/poor coordination, unsteady gait, weakness, sensory deficits, decreased safety awareness. Interventions: Encourage to transfer/change positions slowly (4/11/23). Provide assistance to transfer and ambulate as needed. Have commonly used articles within easy reach. Maintain bed in low position. (4/2/23) Review of Resident #76's fall incident report, dated 4/18/23, indicated he/she was found by staff on the floor of the hallway at 4:45 P.M. In response to the fall the intervention implemented was to reinforce the need to call for assistance; an intervention that would not be effective due to Resident #76's cognitive deficits. Review of Resident #76's fall incident report, dated 4/27/23, indicated that at 4:10 P.M., Resident #76 was heard calling for help and found on the floor of his/her room. Resident #76 was sent to the hospital and required staples for a head laceration. During an interview with the Director of Nursing (DON) and the Administrator, the DON said that after a resident falls the expectation is for staff to investigate the cause of the fall and update the Resident care plan with appropriate intervention(s). The DON said that after Resident #76's initial fall on 4/18/23, the facility wanted to utilize alarms as an intervention, but Resident #76's family declined. The DON said that because of their declination, the facility implemented the use of reinforcement to call for help, despite Resident #76's impaired cognitive status. 3. For Resident #103, the facility failed to develop and implement an elopement risk care plan after Resident #103 was identified as being at risk for elopement. On 5/30/23, Resident #103 eloped from the facility and was found at a senior center 2.5 miles away from the facility. Review of facility's policy titled Wandering and Elopement, dated March 2019, indicated: * If identified at risk for wandering, elopement or other safety issues, the Resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #103 was admitted to the facility in April 2023 with diagnosis including schizophrenia, encephalopathy and dementia. Review of Resident #103's most recent Minimum Data Set assessment, dated 4/17/23, indicated Resident #103 scored 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact and requires physical assistance for ambulation and transfers. Review of the clinical record indicated Resident #103 had a court appointed Guardian for decision making due to incapacity, effective July 2020. Review of Resident #103's elopement risk evaluation, dated 4/20/23, indicated Resident #103 was at risk for elopement and walks around unit asking for the exit door. The evaluation also indicated that Resident #103's care plan would be updated and revised based on the evaluation. Review of Resident #103's care plans failed to indicate any elopement risk care plan or interventions, methods or means for staff to monitor his/her whereabouts after having been identified as being at risk for elopement. Review of Resident #103's incident report dated 5/30/23 indicated that Resident #103 was asking to speak with someone about being discharged home and staff placed a call to the case-manager to speak with him/her at 9:41 A.M. A written statement by the case-manager indicated that she had spoken with Resident #103 on 5/25/23 because Resident #103 was asking to be discharged to a shelter. The report indicated that Resident #103 then told staff he/she was going outside for fresh air. Witness statements from staff indicated that Resident #103 was observed seated on the front patio with his/her walker at approximately 9:45 A.M., and 10:30 A.M The report indicated that Resident #103 was noted to be missing from the building at approximately 11:00 A.M The report indicated that the police were notified at 11:15 A.M. and at approximately 12:50 P.M., the facility received a call from the Senior Center that Resident #103 was there; approximately 2.5 miles away. During an interview with the Administrator and the Director of Nursing on 6/1/23 at 12:25 P.M., they said that Resident #103 had been identified as a high risk for elopement but no care plan was developed to prevent his/her elopement. They said that Resident #103 was granted access to sitting outside unsupervised despite being an identified elopement risk and then eloped from the facility.

Based on record review, observation and staff interview, the facility failed to ensure that for one resident, (#7) of 24 sampled residents, care and services were provided to prevent a pressure ulcer from developing. Findings include: For Resident #7 the facility failed to implement interventions to prevent a pressure ulcer from developing in a Resident at risk for the development of pressure ulcers and failed to identify a pressure ulcer despite the Resident requiring total care for bathing, dressing and positioning until it was unstageable. Resident #7 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE], indicated the Resident was at high risk for the development of pressure ulcers but his/her skin was currently intact. Further review indicated the Resident was an extensive assist of 2 people for repositioning and totally dependent for dressing, bathing and grooming. Review of the clinical record, a nurses note dated 1/9/17, indicated the development of a new stage 2 pressure ulcer that was partially covered in slough ( an incorrect coding, as the wound bed of stage 2 pressure ulcers are clean and without the presence of slough). Review of the Facility document titled Pressure Ulcer Record and dated 1/9/17, indicated that the wound was unstageable however further review of the document indicated a wound measuring 1.5 centimeters (cm) in length by 0.5 cm in width by .25 cm, in depth, indicating an open wound with slough that does not obscure the depth of the wound ( a stage 3 definition), but characterized on the document as unstageable. Review of the Facility document titled Pressure Ulcer Record and dated 5/24/17, indicated a deterioration of the wound size to 1.6 cm length by 0.5 cm width by 0.6 cm in depth and characterized as a stage 3. Review of the Resident's Care plan dated 8/15/14, indicated interventions to prevent the development of skin breakdown including: *Pressure redistributing device on bed and wheelchair *Barrier cream to perianal area/buttocks as needed *Encourage and assist to consume fluids *Encourage and assist to reposition; use assistive devices as needed *Observe skin condition with activities of daily living (ADL) care daily; report abnormalities *Provide preventative skin care routinely and as needed *Refer to therapy plan of treatment in the medical record for more detail On 5/31/17, at 4:50 P.M., the Surveyor observed Resident #7 lying in bed on his/her back in bed on top of a regular mattress. On 5/31/17, at 4:55 P.M., Nurse #1 said that the Resident was lying on a regular mattress and said we really should put him/her on a pressure relieving mattress. On 5/31/17, at 5:30 P.M. the DNS said that the Resident was on a regular mattress. On 6/1/17, at 7:30 A.M., the Surveyor observed Resident #7 to be lying in bed on a pressure relieving low air loss mattress. The Surveyor asked Resident #7 how he/she liked the new mattress and he/she said he/she was more comfortable now.

Based on record review and interviews, the Facility failed to ensure for 1 of 6 sampled residents (Resident #1) that Certified Nurse Aide (CNA) #1 selected the correct sling size for transferring Resident #1, as instructed by the "Sizing Guides for Arjo slings" and CNA Competency Assessments. Per Facility Internal Investigation findings, on 1/20/2012, CNA #1 knowingly used the incorrect sling size, "extra extra large" rather than the assessed size of extra large; CNA #1 then incorrectly wrapped the ends of the sling around the arms of the lift in an effort to take up the slack. Per Facility Internal Investigation findings, CNA #1 did not follow procedure and did not inform nursing staff that the appropriate size sling was not readily available, consequently, Resident #1 fell out of the sling to the floor and sustained a laceration of the scalp.Resident #1 was transferred to the Hospital. A CAT (computed axial tomography) scan showed that Resident #1 had a subarachnoid hemorrhage. It also showed that Resident #1's ventricular- peritoneal shunt passed through both lateral ventricles. Findings include: The January, 2006 Face Sheet indicated that Resident #1 was admitted to the Facility January, 2006 with [DIAGNOSES REDACTED]. Resident #1's Plan of Care interventions to prevent falls, dated February, 2011, included use of the mechanical lift with a 2 person assist for transfers. The Facility's Policy on the Mechanical Lift, effective as of 5/1/11, included: to select the appropriate sling and to follow all manufacturer's guidelines. The quarterly Minimum Data Set (MDS) assessment, completed 10/27/2011, Indicated that Resident #1 was totally dependent for transfers. The Facility's Internal Investigation findings of 1/23/12, indicated that an interview with the assigned CNA (CNA) #1 revealed that he used an extra, extra large sling pad for the transfer. CNA #1 stated that he was aware of the size that should have been used, but he did not see a pad in the Resident's (Resident #1's) room. CNA #1 stated that he went to the laundry and found an extra, extra large sling pad. CNA #1 stated that he knew the pad was bigger than it should have been so he wrapped the ends of the sling around the arms of the lift in an effort to take up the extra slack During his interview, CNA #1 stated that he did not alert anyone of the need for a pad in an effort to locate one that was the correct size. During the transfer one side of the sling pad came out of the lift arm as it was not correctly secured. Without notifying a licensed nurse he alone made the decision to use a larger sling and in doing so manipulated use of the sling to 'better secure" the resident. The Surveyor interviewed the Director of Nurses (DON) on 2/15/12 at 3:25 PM. The DON said on 1/20/12, after Resident #1 fell , CNA #1 told her that Resident #1 required an extra large sized sling, however, CNA #1 used a double extra large sling. The DON said she observed that one side of the sling supporting one leg, was no longer connected to the mechanical lift. The DON said the other side of the sling wrapped around the bar and then connected to the lift. The Hospital Discharge Summary, dated 1/24/12, indicated that Resident #1 sustained a laceration of the scalp. A CAT (computed axial tomography) scan showed her to have a subarachnoid hemorrhage.It also showed that Resident #1's ventricular peritoneal shunt passed through both lateral ventricles. The Document titled Warnings and Safety Instructions indicated to always carefully assess the patient for the correct size of sling. The Document indicated to always check that the sling attachment clips are fully in position before and during the commencement of the lifting cycle, and in tension as the patient's weight is gradually taken up. The Sales Representative, from the mechanical lift company, was interviewed on 2/16/12 at 1:15 PM. The Sales Representative stated that the shape, length and weight of an individual assisted in determining the correct size sling. The Sales Representative said the use of the mechanical lift incorrectly or the use of the wrong size sling could cause an accident. The Sales Representative said one size larger than the assessed sling size, would not be a great risk unless it was two or more sizes greater. The Sales Representative said the incorrect use of the sling and mechanical lift would pose more of a risk. The Sales Representative said that wrapping the sling around the bar before attaching the sling to the clip should not be done. The Sales Representative said the potential would exist for less tention on the clip which may cause the sling to unclip and unwrap. The Sales Representative said that wrapping the sling around a bar would not be necessary if the correct size sling were used. CNA #1 was interviewed on 2/15/12 at 2:25 P.M. CNA #1 said no one ever told CNA #1 the correct size slings to use for residents. CNA #1 said CNAs decided which sling to use based on whatever sling was available. CNA #1 said no one ever told CNA #1 what to do for a sling which was too large. CNA #1 said CNA Care Cards never noted the size of the sling to use for a resident. CNA #1 said on 1/20/12, CNA #1 and CNA #2 transferred Resident #1 using the mechanical lift and Resident #1 fell . CNA #1 said CNA #1 did not wrap the sling around the bar prior to transferring Resident #1. CNA #1 said Resident #1 fell to the floor while up in the mechanical lift. The Marisa Lift (mechanical lift) Competency Assessment signed by CNA #1 and dated (2/13/ 08), indicated that CNA #1 met the mechanical lift competency requirements including "Selects the correct size sling for patient". The Attendance Sheet for the Nursing Assistant Skills Fair signed by CNA #1 and dated (April, 2011) indicated that CNA #1 received education including transfer technique, chair to bed transfer, and mechanical lift safety. The Facility Internal investigation indicated that CNA #1 knew how to do the transfer, he knew the size of the pad needed, and that he was not using the correct size pad for the transfer. CNA #2 was interviewed on 2/15/12 at 1:25 P.M. CNA #2 said he was an orientee assigned to work with CNA #1. CNA #2 said prior to 1/20/12, the Educator directed CNA #2 to make sure that the sling went from the coccyx to half way up the skull. CNA #2 said on 1/20/12, CNA #1 wrapped the sling around the bar of the mechanical lift prior to Resident #1's transfer. CNA #2 said CNA #1's wrapping of the sling around the bar was unfamiliar practice to CNA #2, the act was not questioned nor was the transfer prevented. CNA #2 said CNA #1 and CNA #2 checked that the clips were secure before the transfer. CNA #2 said Resident #1 fell out of the sling to the floor. The Facility Internal Investigation indicated that CNA #1 knew how to do the transfer, he knew the size of the pad needed, and that he was not using the correct size pad for the transfer.

Based on record review and interview, the facility failed to conduct a comprehensive assessment of one resident (#20) in a total sample of 24, within 14 days after determining there was a mood state decline and a significant change in the resident's weight that was not resolving with standard disease related clinical interventions and required an interdisciplinary review of the care plan. Findings include: 1. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident as having no mood indicators, an initial weight of 201 pounds and being independent in eating. The only care plan for nutrition was dated 1/22/11 and was related to diabetes with interventions that included to monitor weights. On the quarterly MDS, dated [DATE], the resident was coded as being 190 pounds and as having a significant weight loss ( 11 pounds in 3 months). The resident also was coded as declining in mood state, developing many mood indicators with a mood score of 18/27. The next quarterly MDS, dated [DATE], indicated the resident now weighted 169 pounds and was again coded as a significant weight loss. The RD documented on 7/21/2011, that the resident "was within ideal body weight" but "continued weight loss not favorable." Review of the all physician progress notes [REDACTED]. Interview with the MDS coordinators on 11/3/2011, MDS RN #1 and MDS RN #2, at 12:00 P.M., revealed they were unsure that significant weight loss alone would trigger a significant change MDS. When asked about the resident's decline in mood state from no indicators to many and new onset of [MEDICAL CONDITION], the MDS RN's responded that the resident had labile mood. Asked how they knew this, MDS RN #1 responded the resident had long standing [MEDICAL CONDITION]. However, the resident was a new admission since January 2011 and the mood had declined, since admission, confirming a change in the resident's mental status since the admission MDS. Despite 6 months of irreversible weight loss, mood decline and period of [MEDICAL CONDITION] during the second quarter and multiple hospitalization s for recurrent Urosepsis, the facility did not conduct a new comprehensive assessment of the resident by the interdisciplinary team, as required. Please also see F325.

Based on record review and interview, the facility failed to ensure one resident (#20) in a total sample of 24, did not have unplanned significant weight loss, without interdisciplinary assessment and interventions that were consistently implemented in attempt to prevent weight loss, unless the resident's clinical condition demonstrated that this was not possible. Findings include: 1. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident as having no mood indicators, an initial weight of 201 pounds and being independent in eating. The only care plan for nutrition was dated 1/22/11 and was related to diabetes with interventions that included to monitor weights. On the quarterly MDS, dated [DATE], the resident was coded as being 190 pounds and as having a significant weight loss ( 11 pounds in 3 months). The resident also was coded as declining in mood state, developing many mood indicators with a mood score of 18/27. Review of the dietitian's progress notes revealed the Registered Dietitian (RD) noted weight loss on 4/5/2011 and planned to try to liberalize diet from two gram sodium, low fat low cholesterol, low concentrated sweet to no added salt low concentrated sweet, low fat, low cholesterol diet ( removing the salt restriction from two grams to low salt). This diet change does not increase calories but only increases the salt from two grams to four grams a day. For weight stabilization or gain, a resident needs an increase or stable calorie intake. The next RD note was 5/20/2011 when it was noted the resident now weighed 186.2 pounds and intakes were poor to fair. The RD noted the resident had been recently started on antibiotics for a urinary tract infection and was being followed by psychiatry for depression. The RD's plan was to start a supplement three times a day. The RD suggested an appetite stimulant, [MEDICATION NAME], and noted the physician was notified. Record review revealed the [MEDICATION NAME] was never implemented. The Nutrition care plan was revised to include the problem of significant weight loss with a goal of stable weight 175 plus or minus 5# ( resident weighed 186), intake greater the 75% for two of three meals and intervention to liberalize diet to No added salt (NAS), low concentrated sweet diet and continue to monitor weights. Record review revealed the resident had been hospitalized for [REDACTED]. Upon return, the resident's weight was 174 pounds. The next quarterly MDS, dated [DATE], indicated the resident now weighted 169 pounds and was again coded as a significant weight loss. The RD documented on 7/21/2011, that the resident "was within ideal body weight" but "continued weight loss not favorable." Plan was to add Magic cup at supper." On 8/19/2011, the RD noted the resident's weight to be 165.4 after a 2 day hospitalization for mental status changes. During the hospitalization , metastasis of the previous [MEDICAL CONDITION] was suspected. The RD noted the resident returned on a puree diet and upgraded the diet to soft. The next RD note was not until 10/22/2011. RD noted the resident was out to hospital again in August for two days with Urosepsis. The RD note stated resident was on a regular diet since 8/17/2011 per speech therapy and on supplements three times a day and a magic cup at supper. However, review of medication administration records and physician orders [REDACTED]. The above interventions recommended by the RD were not implemented until 10/21/11. The facility failed to implement recommendations made by the facility RD in a timely manner to address unplanned significant weight loss for Resident #20.