Every finding on record at Care One at Weymouth

Based on records reviews and interviews, for one of three sampled residents (Resident #1), who was alert and able to make his/her needs known, the Facility failed to ensure he/she was treated in a respectful and dignified manner by staff, when Certified Nurse Aide (CNA) #1 was witnessed engaging in an interaction with Resident #1 that was unprofessional and per Resident #1, resulted in him/her being embarrassed while in the company of other residents.Findings include:Review of the Facility's Policy titled Residents Rights, dated March 2019, indicated employees shall treat all residents with kindness, respect, and dignity. The Policy indicated residents' rights included the right to a dignified existence. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/16/26, indicated that Resident #1 reported that CNA #1, in a joking manner, used of both her index fingers to lift each of his/her (Resident #1's) breasts and then released them making him/her uncomfortable. Review of Resident #1's medical record indicated his/her diagnoses included altered mental status, anxiety and delusional disorder.Review of Resident #1's admission Minimum Data Set assessment, dated 04/09/26, indicated that during a brief assessment for mental status he/she had moderate problems with memory and thinking.Review of the Police Department Incident Report, dated 06/17/26, indicated that Resident #1 told the Police Officer that CNA #1 turned to him/her, took her (CNA #1s) two pointer fingers, moved them up on his/her (Resident #1) breasts, and laughed as she (CNA #1) did it. The Incident Report indicated Resident #1 said he/she felt stunned by the incident and that other residents told him/her to report it.During a telephone interview on 07/17/26 at 11:35 A.M., Resident #1 stated he/she had reported the incident to a Police Officer, and he/she declined to be interviewed or provide any information to the Surveyor.During an interview on 07/14/26 at 12:00 P.M., CNA #2 said during lunchtime on 06/16/26 she and CNA #1 entered a resident room to deliver two meal trays to the residents residing there. CNA #2 said they walked around Resident #1 who was near the doorway visiting the residents who resided in that room. CNA #2 said Resident #1 slapped CNA #1's buttocks as she (CNA #1) walked by him/her to put a tray down, that Resident #1 called CNA #1 by a nickname, and CNA #1 laughed in response. CNA #2 said after the meal trays were placed down, CNA #1 turned to leave the room, and approached Resident #1. CNA #2 said CNA #1 quickly put two of her fingers under Resident #1's breasts over his/her clothing, lifted Resident #1's breasts up, released them, repeated the nickname directed at her (CNA #1) back at Resident #1, laughed and then she and CNA #1 left the room.CNA #2 said although they (CNA #1 and Resident #1) joked often, that this was the first time she witnessed Resident #1 touch CNA #1 (slap CNA #1's buttocks) or CNA #1 touch Resident #1 (lifting up and releasing his/her breasts). CNA #2 said about 5 minutes later, Nurse #1 approached her and asked what had happened between Resident #1 and CNA #1.During an interview on 07/14/26 at 11:25 A.M., Nurse #1 said on 06/16/26 sometime around lunchtime, Resident #1 was overheard stating that no one liked him/her. Nurse #1 said she approached Resident #1 and asked why he/she would say that. Nurse #1 said Resident #1, without demonstrating, told her a CNA (later identified as CNA #1) walked by him/her, touched his/her breasts, laughed and walked away. Nurse #1 said she immediately reported the incident to her supervisor.During an interview on 07/14/26 at 1:50 P.M., the Unit Manager said she met with Resident #1 immediately after being notified of the alleged incident. The Unit Manager said Resident #1 was upset, and crying. The Unit Manager said Resident #1 told her he/she was embarrassed because of an incident that had occurred while he/she was talking to residents in their room. The Unit Manager said Resident #1 told her that as CNA #1 was leaving that room, she lifted his/her (Resident #1's ) breasts with her hands, then released them and walked away laughing. The Unit Manager said Resident #1 told her that CNA #2 was also in the room at the time of the incident.During an interview on 07/14/26 at 10:35 A.M., the Director of Nurses (DON) said Resident #1 told her a CNA (later identified as CNA #1) lifted his/her breasts using her index fingers, released them and laughed. The DON said Resident #1 said he/she did not think CNA #1 meant anything by it, but that the incident (which happened in front of other residents) had made him/her upset and embarrassed. The DON said although CNA #1 denied the allegation, Resident #1 provided a consistent account of the incident and that it had also been witnessed by CNA #2. The DON said CNA #1's employment was terminated.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was newly admitted related to his/her need for skilled nursing services, the Facility failed to ensure it provided treatment and care in accordance with professional standards of quality care, when during two separate Physician's visits, his/her provider indicated there were new treatment and/or medication orders for Resident #1, however they were not transcribed and entered as a Physicians order in a timely manner.Findings include:Based on the Facility Policy titled Medication and Treatment Orders, dated as last revised 07/2016, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing.The Policy further indicated the following;-Medications shall be administered only upon the written order of a person duty licensed and authorized to prescribe such medication in this State;-Drugs and biological orders must be recorded on the Physician's Order sheet in the resident's chart; and-All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order.Resident #2 was admitted to the Facility in 11/2025 diagnoses include a urinary tract infection, status post fall, diabetes mellitus, and asthma.Review of Resident #2's Physician Progress Note, dated 11/28/25, indicated he/she was admitted related to a subacute level of service, and his/her plan was to include a repeat urinalysis culture with sensitivity (UA/CS) and add back his/her glargine (Lantus, long-acting insulin) at a lower dose.Review of Resident #2's Medical Record, from 11/28/25 through 12/23/25, including but not limited to physician's orders, Medication Administration Records (MAR), and nurse progress notes, indicated there was no documentation to support he/she had physician's orders to obtain a repeat UA/CS or an order for Lantus at a lower dose. There was also no documentation to support nursing contacted the Physician to clarify the orders.Review of Resident #2's Physician Progress Noted, dated 12/23/25, indicated to administer low dose Lantus six (6) units (u) every A.M. (morning) subcutaneously. Review of Resident #2's MAR, dated 12/23/25 through 12/29/25, (date of transfer/discharge) indicated there was no documentation to support he/she had physician's orders to administer Lantus 6 unit every A.M. subcutaneously. There was also no documentation to support nursing contacted the Physician to clarify the order.During an interview on 02/25/26 at 5:39 P.M., Nursing Supervisor #2 said that Physician's Orders are put into Point Click Care PCC, electronic medical record) system by the physician's themselves and if the physician does not put the orders in themselves, they should be informing nursing to do so as a verbal order.During an interview on 02/26/26 at 8:51 A.M., Unit Manager #2 said that physicians put their orders for each resident into PCC and said if they are unable, they will give a verbal order to the nurse responsible for the resident at the time of the visit and the nurse will enter the order.During an interview on 02/26/26 at 9:30 A.M., Physician #2 said he was not aware that the intended orders (in his 11/28/25 and 12/23/25 progress notes) had not been entered for Resident #2 after being written in his progress note.Physician #2 said that he usually puts his orders right into the PCC system and said that he must have missed putting in the orders that he intended for Resident #2. During an interview on 02/26/26 at 2:40 P.M., the Director of Nurses (DON) said that she was unaware of the intended physician's orders within the progress note [that were not acted upon] written by Resident #2's physician.The DON said the Facility's expectation is that all physicians either input their orders directly into the PCC system or communicate with nursing staff with a verbal or written order so the nurse can enter the order and be placed into PCC for each resident.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #2), the Facility failed to ensure they maintained complete and accurate medical/treatment records when nursing documentation nursing on his/her Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) were omitted, with some care areas left blank.Findings include:Review of the Facility Policy titled Charting and Documentation, dated as last revised July 2017, indicated that all services provided to the resident, progress towards the care plan goals, or any changes in the resident medical, physical, functional or psychosocial condition, shall be documented in the residents medical record, The Medical record should facilitate communication between the interdisciplinary team regarding the residents condition and response to care.The Facility indicated medication administration and treatments or services performed must be documented in the resident's medical record.Resident #2 was admitted to the Facility in 11/2025 diagnoses include a urinary tract infection, status post fall, diabetes mellitus, and depression.Review of Resident #2's Physician's Orders, dated 12/01/25 through 12/29/25, indicated he/she had orders for the following:-Vital Signs every evening shift;-Diabetic foot care daily every evening at bedtime;-Behavior tracking for depression every shift; and -Evaluate for pain every shift.Review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 12/01/25 through 12/29/25, indicated that on Resident #2's MAR and/or TAR documentation for the following were omitted (left blank);-Vital Signs every evening shift; (omitted and/or left blank) on 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25, 12/16/25, 12/18/25, 12/20/25, and 12/25/25.-Diabetic foot care daily every evening at bedtime; (omitted or left blank) on 12/06/25-12/10/25, 12/16/25, 12/18/25, 12/20/25, 12/21/25, 12/25/25, and 12/26/25.-Behavior tracking for depression every shift; (omitted and/or left blank on the evening shift) on 12/09/25, 12/10/25, 12/16/25, 12/18/25, 12/20/25, and 12/25/25.-Evaluate for pain every shift; (omitted and/or left blank on the evening shift) on 12/09/25, 12/10/25, 12/16/25, 12/18/25, 12/20/25, and 12/25/25.During an interview on 02/25/26 at 2:25 P.M., Supervisor #1 said that daily documentation is to be done every shift and said he was not sure why Resident #2's record had missing documentation. During an interview on 02/26/26 at 1:28 P.M., Unit Manager #1 said that nursing should be documenting daily on their residents and both the MAR and TAR should be completed daily as the care is provided.During an interview of 02/26/26 at 2:40 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that all nurses complete their required documentation daily and in a timely manner. The DON said that documentation in MAR's and TAR's should be done by nursing upon completion of the administration of a medication or treatment.

Based on interview and record review, the facility failed to ensure the drug regimen for one Resident (#56), from a total sample of 28 residents, was free of unnecessary drugs. Specifically, the facility failed to ensure two oral antibiotic medications (Doxycycline and Amoxicillin/Clavulanate) were not given in excessive duration resulting in the Resident receiving five unnecessary doses of oral antibiotics while on intravenous (IV) antibiotics. Findings include:Review of the facility's policy titled Adverse Consequences and Medication Errors, last revised June 2025, indicated but was not limited to:-A medication error is defined as the preparation or administration of drugs or biological which is not accordance with provider's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.-Examples of medication errors include: -unauthorized drug- a drug administered without a provider's order. Resident #56 was admitted to the facility in December 2025 with diagnoses including acute osteomyelitis (an infection in a bone) of the left ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA, Staphylococcus aureus bacteria that are resistant to treatment with one of the semi-synthetic penicillin), and cutaneous abscess (painful, pus-filled pocket under the skin, usually caused by a bacterial infection) of the left foot. Review of the Minimum Data Set assessment, dated 12/23/25, indicated Resident #56 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and he/she was receiving IV antibiotics. During an interview on 1/12/26 at 9:02 A.M., Resident #56 said he/she went to an appointment on 1/9/26 and was told by the doctor to continue their IV antibiotics for two more weeks then switch to oral antibiotics. Review of Resident #56's Hospital Discharge summary, dated [DATE], indicated but was not limited to:-Antibiotics: -Daptomycin (antibiotic) 8 milligrams (mg) per kilogram (kg) every 24 hours and continue through 1/9/26 -Ceftriaxone (antibiotic) 2 grams (gm) every 24 hours and continue through 1/9/26 -14-day course of Doxycycline (antibiotic) 100 mg every 12 hours and Amoxicillin/Clavulanate (antibiotic) 875/125 mg every 12 hours from 1/10/26 to 1/23/26. Review of Resident #56's Physician's Orders indicated but was not limited to:-Ceftriaxone Sodium Injection Solution Reconstituted 2 grams (gm) intravenously in the morning for osteomyelitis until 01/23/26, dated 1/9/26-Daptomycin Intravenous Solution Reconstituted 575 milligrams (mg) intravenously in the evening for osteomyelitis until 1/23/26, dated 1/9/26-Doxycycline Capsule 100 mg, give 1 capsule by mouth two times a day for osteomyelitis for 14 days Start 1/24/26, dated 1/13/26-Amoxicillin/Clavulanate tablet 875-125 mg, give 1 tablet by mouth two times a day for osteomyelitis for 14 days Start 1/24/26, dated 1/12/26 Review of Resident #56's discontinued Physician's Orders indicated but was not limited to:-Doxycycline Capsule 100 mg, give 1 capsule by mouth two times a day for osteomyelitis for 14 days until 1/23/26, start date 1/10/26 discontinue date 1/12/26-Amoxicillin/Clavulanate tablet 875-125 mg, give 1 tablet by mouth two times a day for osteomyelitis for 14 days until 1/23/26, start date 1/10/26 discontinue date 1/12/26 Review of Resident #56's Physician's Consult, dated 1/9/26, indicated but was not limited to:-Continue Ceftriaxone and Daptomycin daily-Follow up in two weeks Review of Resident #56's January Medication Administration Record (MAR) indicated five doses of Doxycycline and Amoxicillin/ Clavulanate were administered to him/her on the following days and time:-1/10/26 at 9:00 A.M. and 9:00 P.M.-1/11/26 at 9:00 A.M. and 9:00 P.M.-1/12/26 at 9:00 A.M. During an interview on 1/13/26 at 10:57 A.M., Nurse Practitioner #1 said Resident #56 should not have received two different IV antibiotics and two different oral antibiotics. She said Resident #56 should have only received IV antibiotics to avoid duplicate/excessive therapy and potential adverse reaction. During an interview on 1/13/26 at 11:04 A.M., Nurse #5 said Resident #56 went out to a doctor's appointment on 1/9/26 and returned to the facility with new orders to continue their IV antibiotics for two more weeks. She said she did not know if Resident #56 was supposed to receive Doxycycline and Amoxicillin/Clavulanate, but she had administered them yesterday morning (1/12/26) as they appeared on the MAR. She said someone had been talking about clarifying Resident #56's antibiotic orders because four antibiotics is too many. During an interview on 1/13/26 at 11:28 A.M., Unit Manager #4 said Resident #56 returned from a doctor's appointment on 1/9/26 and an order to continue his/her IV antibiotics for two additional weeks. She said Nurse #5 had put an order in to continue the IV antibiotics for two additional weeks and an order to start Doxycycline and Amoxicillin/Clavulanate twice daily on 1/24/26 for 14 days, but she had not discontinued the previous order, dated to start on 1/10/26, for Doxycycline and Amoxicillin/Clavulanate twice daily. She said when she came in on 1/12/26 she had discovered Resident #56 had received their two IV antibiotics as ordered and oral Doxycycline and Amoxicillin/Clavulanate twice daily for five doses which was too many antibiotics. She said Resident #56 should not have received the oral Doxycycline and Amoxicillin/Clavulanate until 1/24/26. During an interview on 1/13/26 at 1:46 P.M., the Director of Nursing said she was notified of the medication error for Resident #56. She said Resident #56's Doxycycline and Amoxicillin/Clavulanate should not have been administered until 1/24/26 but the order for them to start on 1/10/26 had not been discontinued resulting in Resident #56 receiving duplicate antibiotic therapy.

Based on observations and interviews, the facility failed to follow infection prevention and control practices. Specifically, the facility failed to:1. Ensure proper cleaning of resident shared equipment between resident use; and2. Ensure effective hand hygiene practices and appropriate personal protective equipment (PPE) were utilized when entering and exiting resident rooms, including residents on transmission-based precautions (implemented in addition to standard precautions in order to prevent or control infections.), to prevent the potential spread of infection. Findings include:1. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, last revised September 2022, indicated but was not limited to:-Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard.-Reusable items are cleaned and disinfected or sterilized between residents.-Durable medical equipment is cleaned and disinfected before reuse by another resident. Review of CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, indicated but was not limited to:-Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood pressure cuffs) prior to use on another patient or when soiled. On 1/8/26 between 8:22 A.M. and 9:05 A.M., the surveyor made the following observations:-Nurse #5 exited Resident #56's room with the vital signs machine and failed to clean and disinfect it.-Nurse #5 entered Residents #58 and #22's room with the vital signs machine. Nurse #5 obtained vital signs for Resident #22, and then for Resident #58. She failed to clean and disinfect the vital signs machine between residents. She then exited the room.-Nurse #5 entered Residents #40 and #23's room with the vital signs machine. Nurse #5 obtained vital signs for Resident #23 and then for Resident #40. Nurse #5 failed to clean and disinfect the vital signs machine between residents. She then exited the room.-Nurse #5 entered Resident #24's room with the vital signs machine. Nurse #5 obtained the vital signs for Resident #24 and brought the vital signs machine into the hallway. Nurse #5 failed to clean and disinfect the vital signs machine when she exited the room. On 1/8/26 at 12:07 P.M., the surveyor observed the following:-Nurse #5 entered a Resident's room with a glucometer (a portable medical device that measures the glucose level in a tiny drop of blood)-Nurse #5 exited the room and returned the glucometer to the medication cart.-Nurse #5 failed to clean and disinfect the glucometer machine prior to returning the glucometer to her medication cart. During an interview on 1/8/26 at 12:10 P.M., Nurse #5 said equipment that is shared between residents must be wiped cleaned and disinfected between residents or after use for a resident. Nurse #5 said she had not wiped down the vital signs machine between residents, but she should have. Nurse #5 said she used the glucometer to check a Resident's blood glucose level, and the glucometer was not a single resident glucometer but shared between multiple residents. She said she had not wiped down the glucometer after checking the blood glucose level, but she should have. During an interview on 1/13/26 at 1:46 P.M., the Director of Nursing (DON) and the Infection Preventionist (IP) said all shared equipment including the vital sign machine and glucometer need to be wiped down prior to use and between being used for each resident to prevent the spread of infection. 2. Review of the facility's policy titled Clostridioides (Clostridium) Difficile (C. Diff, a highly contagious bacterium that causes diarrhea and inflammation of the colon), last revised December 2024, indicated but was not limited to:-Steps toward prevention and early interventions include:-Frequent handwashing with soap and water by staff and residents; and-Wearing gloves and a gown when caring for residents with potential infectious diarrhea or when handling feces or articles contaminated with feces.-When caring for residents with C. difficile, staff are to maintain vigilant hand hygiene. Handwashing with soap and water is superior to ABHR (alcohol-based hand rub) for mechanical removal of C. difficile spores from hands. Review of the facility's policy titled Isolation- Categories of Transmission-Based Precautions, last revised September 2022, indicated but was not limited to:-Transmission-based precautions are initiated when a resident develops signs and symptoms of transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.-Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.-Contact Precautions-Contact precautions are implemented for residents known or suspected of being infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident-care items in the resident's environment.-Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggests an increased potential for extensive environmental contamination or risk of transmission of pathogen, even before specific organism can be identified.-Staff wear gloves when entering the room.-Staff wear a gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after the gown is removed. Resident #190 was admitted to the facility in January 2026 with diagnoses including C. diff. Review of Resident #190's current Physician's Orders indicated but was not limited to:-Maintain Contact Plus Precautions related to C. diff infection every shift, dated 1/4/26 On 1/7/26 at 9:35 A.M., the surveyor observed Resident #190 in his/her room with a Contact Plus Precaution sign outside the door of their room which indicated but was not limited to:-STOP CONTACT PLUS-In addition to Standard Precautions Staff and Providers Must:-Must clean hands before entering a resident's room.-Gown.-Glove.-Wash Hands with soap and water before exiting a resident's room.-Hand sanitizer alone, is not sufficient when exiting a resident's room. On 1/7/26 at 9:39 A.M., the surveyor observed the following:-Certified Nursing Assistant (CNA) #2 walk into Resident #190's room and walk over to his/her bed. CNA #2 donned a gown but failed to don gloves. On 1/7/26, the surveyor observed the following:- At 12:06 P.M, CNA #3 entered Resident #190's, prior to entering his/her room she failed to perform hand hygiene and failed to don (put on) PPE.- At 12:14 P.M., CNA #3 exited Resident #190's room and failed to use soap and water to clean her hands. On 1/8/26 at 8:48 A.M., the surveyor observed the following:-Nurse #5 entered Resident #190's room carrying two cups of water.-Nurse #5 failed to perform hand hygiene and don PPE prior to entering Resident #190's room.-Nurse #5 gave one of the two cups of water to Resident #190.-Nurse #5 exited Resident #190's room and failed to wash her hands with warm soapy water.-Nurse #5 entered another Resident's room and gave him/her the second cup of water.-Nurse #5 failed to perform hand hygiene prior to entering the other Resident's room. During an interview on 1/13/26 at 10:43 A.M., CNA #2 said Resident #190 was on precautions for C. Diff. She said she should have donned a gown and gloves prior to entering his/her room. CNA #2 said she should have used warm soapy water prior to exiting Resident #190's room but she had not. During an interview on 1/13/26 at 11:09 A.M., Nurse #5 said Resident #190 was on Contact Precautions for C. Diff. She said staff must perform hand hygiene and don PPE prior to entering Resident #190's room and wash their hand with soap and water when exiting the room. Nurse #5 said she had not donned PPE or performed hand hygiene prior to entering and exiting Resident #190's room but should have. Nurse #5 said she should not have brought a cup of water for another resident into Resident #190's room to decrease the risk of infecting the other resident. During an interview on 1/13/26 at 11:33 A.M., Unit Manager #4 said Resident #190 was on contact precautions for C. Diff. She said all staff must perform hand hygiene and don PPE prior to entering Resident #190's room and wash their hands with warm soapy water after doffing PPE to help prevent the spread of infection. Unit Manager #4 said only drinks intended for Resident #190 should enter his/her room. During an interview on 1/13/26 at 1:46 P.M., the IP said all staff must follow signs for Contact Precaution for Resident #190 to help prevent the spread of C. diff.

Based on record review and interviews, the facility failed to ensure staff maintained complete and accurate medical records for one Resident (#153), out of a total sample of 28 residents. Specifically, for Resident #153, the facility failed to ensure his/her medical record included his/her weight results.Review of the facility's policy titled Weight Assessment and Intervention, dated as revised March 2022, indicated but was not limited to:-Weights are recorded in each individual's medical record Resident #153 was admitted to the facility in December 2025 with diagnoses which included bacteremia (bacteria in the bloodstream) and sepsis (the body's reaction to extreme infection). Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, indicated Resident #153 was 71 inches tall, weighed 155 pounds, and had no weight loss or gain. Review of Resident #153's Physician's Orders indicated but were not limited to:-weight every Monday for three weeks, start date 12/22/25 Review of Resident #153's December 2025 Treatment Administration Record (TAR) indicated but was not limited to:-12/22/25: weight signed off as obtained but result was not indicated-12/29/25: weight signed off as obtained but result was not indicated Review of Resident #153's January 2026 TAR indicated but was not limited to:-1/5/26: weight signed off as obtained but result was not indicated Review of Resident #153's December 2025 Documentation Survey Report indicated but was not limited to:-12/24/25: weight obtained but result was not indicated-12/31/25: weight obtained but result was not indicated Review of Resident #153's Weight and Vitals Summary indicated but was not limited to:-1/7/26: 145.6 pounds (lbs.)-1/13/26: 146.6 lbs. During an interview on 1/12/26 at 3:42 P.M., the Dietitian said residents should be weighed on admission and then weekly for 4 weeks. The Dietitian said weights should be recorded in the medical record.During an interview on 1/13/26 at 9:13 A.M., Certified Nursing Assistant (CNA) #1 said weights are completed on Mondays for all residents and documented in the electronic medical record. During an interview on 1/13/26 at 11:27 A.M., Nurse #3 said weights are obtained on Mondays and as needed. Nurse #3 said weights should be recorded in the electronic medical record. During an interview on 1/13/26 at 11:29 A.M., Unit Manager #2 said the dietitian provides a list of weights that need to be obtained. Unit Manager #2 said weights should be recorded in the electronic medical record. Unit Manager # 2 reviewed the medical record and said the medical record indicated the resident was weighed on 12/22/25, 12/29/25 and 1/5/26 but the results were not documented. During an interview on 1/13/26 at 1:22 P.M., the Director of Nurses (DON) said weights should be documented in the medical record and weights should be complete and accurate.

Based on observation, interviews, and records reviewed, the facility failed to ensure residents were free from significant medication errors when one of two nurses observed during the medication pass failed to follow physician orders for an antiseizure medication. Specifically, for Resident #66, with a history of epilepsy (a brain disease that causes repeated seizures due to abnormal electrical signals in the brain), Nurse #1 failed to administer the correct dose of his/her anticonvulsant medication (drugs that control or prevent seizures by calming excessive electrical activity in the brain). Findings include:Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated but was not limited to:-Medications are administered in accordance with prescriber orders Review of Up To Date (an evidence-based clinical resource), Antiseizure medication maintenance therapy and drug monitoring, dated as revised 12/29/2025, indicated but was not limited to:-Studies have shown that those taking therapeutic doses of Levetiracetam have levels in the order of 12 to 46 milligrams/liter (mg/L).-The clinician should impress upon the patient, family, and caregivers the critical need to follow the prescribed antiseizure medication regimen. -The RANSOM (Research on Antiepileptic Nonadherence and Serious Outcomes in Medicaid) study of more than 30,000 epilepsy patients found that nonadherence was associated with a more than threefold risk of mortality compared with adherence. Other consequences include a higher incidence of attendance to emergency departments, hospital admissions, fractures, head injuries, and increased health care costs. Another study in which nonadherence was identified by therapeutic drug monitoring with reference to the patient's own control value found that adherence was a factor in 39 percent of patients admitted to hospital with seizures. Resident #66 was admitted to the facility in September 2024 with diagnoses which included epilepsy. On 1/8/26 at 9:04 A.M., the surveyor observed Nurse #1 prepare and administer medication to Resident #66. Nurse #1 prepared Levetiracetam (an anticonvulsant medication primarily used to prevent and control various types of seizures in people with epilepsy) 500 milligrams (mg) one tablet. Nurse #1 referred to the electronic medication administration order and told the surveyor the order states 1,000 mg give one half tablet, which is equal to 500 mg so the Resident will get one tablet. Review of Resident #66's Physician's Orders indicated but was not limited to:-Levetiracetam 1000mg, give 1.5 tablet by mouth every 12 hours, dated 1/21/25 During an interview on 1/8/26 at 11:15 A.M., Nurse #1 said Resident #66 was administered Levetiracetam 500mg because the order said to give one half of a 1,000mg tablet. Nurse #1 and the surveyor reviewed Resident #66's physician's orders and Nurse #1 said she thought the order said 0.5 tablet and not 1.5 tablets and that Resident #66 received the wrong dose. Nurse #1 said Resident #66 needed two more tablets of Levetiracetam 500mg. During an interview on 1/8/26 at 11:26 A.M., the Director of Nurses (DON) said medications should be administered as ordered and physician's orders should be followed.

Based on interviews and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one Resident (#18), in a total sample of 28 residents. Specifically, the facility failed to assist Resident #18 in their request for discharge planning. Findings include:Review of the facility's policy titled Discharge Summary and Plan, revised in March 2025, indicated the following:-every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan-the discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge-residents are periodically assessed for their interest in returning to the community-if the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place-the facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals are documented in the medical record.-if it is determined that returning to the community is not feasible, it is documented why this is the case and who made the determination Review of the facility's policy titled Social Services, revised in March 2022, indicated the following:-the facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being-the social worker/social service staff are responsible for: making referrals and obtaining needed services from outside entities, helping residents with transitions of care services (for example, community placement options, home care services, transfer arrangements, etc.) Resident #18 was admitted to the facility in November 2023 with a diagnosis of end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/22/25, indicated Resident #18 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of Section S indicated Resident #18 had a health care proxy on file, which was not invoked indicating the Resident was responsible for their own decision making. Review of Section Q indicated there was no active discharge plan for Resident #18 to return to the community and the Resident's clinical record indicated to only ask the Resident about returning to the community on a comprehensive assessment (yearly or with significant change). During an interview on 1/7/26 at 4:10 P.M., Resident #18 said he/she had a problem with the Social Service department. The Resident said he/she wished to return to the community and to live with their significant other and had been asking the facility Social Work staff about the process for four months. The Resident said he/she had attempted to leave a voicemail for the Social Service Department, and the voicemail indicated it was not checked regularly. He/she said they had provided information to someone whom they believed was a Social Work intern, had written down the information, but had never followed up. He/she said another Social Worker had come to speak with him/her about this and the Social Worker had indicated they would make a referral to the Elder Service agency, but the Resident was not sure this had been done. Resident #18 said he/she had a scheduled care plan meeting for the following day (1/8/26) and was looking forward to asking the Social Work staff about how the referrals to outside services were going. Review of all Social Service notes failed to indicate any discussion with Resident #18 regarding wanting to return to the community, where the Resident would like to discharge to, who the supports/care givers in the community would be or if any referrals to local agencies had been initiated to inquire the feasibility of discharge. Review of the consultant psycho-therapy progress notes indicated the following:9/30/25: spoke about relocating (out of state), though unsure about leaving family11/18/25: plans to leave the facility after mid-December when significant other arrives from out of state; discussed wanting to marry significant other and relocate out of state and feels it's their own life and believes he/she deserves happiness. Resident is collaborating with the facility's Social Worker on detailed discharge plans12/2/25: Resident hopeful about being discharged with significant other soon12/16/25: significant other visiting from out of state, Resident contemplating leaving with the significant other with mixed emotions about leaving family but expressing a desire for love and happiness During an interview on 1/13/26 at 9:15 A.M., Social Worker #3 said she had worked part-time for the facility for the previous four years. She said she had been doing remote work (not coming into the facility) for two years. She said she helps in completing quarterly social service progress notes, MDSs and care plans. She said she had completed the most recent MDS for Resident #18. She said she completed Section Q based on information in the medical record and had not spoken directly with Resident #18. She said she had no information on Resident #18 wishing to return to the community. She said in reviewing the Social Service information it looked as though in April 2024 Resident #18 had indicated they would need to stay at the facility and had given up their apartment. She said the note indicated contacting Elder Services if Resident #18 would like assistance at any time transitioning back to the community. She said there was no documentation to indicate the Resident had been referred for services as of this time. During an interview on 1/13/26 at 10:00 A.M., the Director of Social Services said he had worked at the facility for a month and was unfamiliar with the Resident and had not met him/her. During an interview on 1/13/26 at 10:05 A.M., Social Worker #2 said he had started at the facility about two weeks prior and he was unfamiliar with Resident #18 but was the assigned Social Worker. When the surveyor inquired if the Social Worker attended the care plan meeting for Resident #18 which was scheduled for 1/8/26, he said the care plan meetings were scheduled (and showed the surveyor the schedule with Resident #18 scheduled for 1:00 P.M.) but had not been held because he was new to the facility. He said he had not reached out to any of the residents or families with scheduled meetings on 1/8/26 and had not spoken with Resident #18 about rescheduling as of five days later. During an interview on 1/13/26 at 10:11 A.M., Unit Manager #3 said the care plan meetings scheduled for 1/8/26 did not occur because the Social Worker was new and she did not know what the plan was. During an interview 1/13/26 at 10:18 A.M., the Activity Director said the care plan meetings scheduled for 1/8/26 did not occur and she was not sure why. During an interview on 1/13/26 at 10:29 A.M., the former Social Worker (#4) indicated she had worked at the facility until mid-December 2025. She said she was familiar with Resident #18 and had talked in length with the Resident about the Resident's desire to return to the community and live with their significant other out of state. She said she had not referred the Resident to any community agencies for assistance with the feasibility in returning to the community. The Social Worker said she thought that maybe she had been waiting for the significant other to come visit but does not know what happened with this. She said she was not sure why there was no documentation to indicate her discussions with the Resident and their desire to return to the community. During an interview on 1/13/26 at 2:51 P.M., the Administrator said Social Worker #4 should have documented the discussions with Resident #18 regarding wanting to return to the community and the MDS and goals of care should have reflected this. He said he had not directly spoken with Resident #18 about wanting to return to the community but had heard that the Resident wanted to move out of state with their significant other. He said he was aware the significant other had come to visit in December but had not heard of any staff meeting with the significant other to discuss discharge planning or feasibility of discharge. He said as far as he was aware Resident #18 had not been referred to any community agencies for assistance or to determine eligibility to access programs for assistance. He said the care plan meeting scheduled for 1/8/26 should have occurred with Resident #18 and had since been rescheduled.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#56), out of a total of 28 residents. Specifically, the facility failed to change the PICC dressing per professional standards. Findings include:Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, last revised June 2025, indicated but was not limited to the following:- The purpose of the procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or well dressings.- Maintain sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) dressing for all central vascular access devices.- Change the dressing if it becomes damp, loosened or visibly soiled and: - at least every 7 days for TSM dressing; - at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured). Review of the Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections, last revised October 2017, indicated but was not limited to:- Catheter Site Dressing Regimens: - Replace dressings used on short-term CVC (central vascular catheter) sites every 2 days for gauze dressings. - Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings.(https://www.cdc.gov/infection-control/media/pdfs/Guideline-BSI-H.pdf) Review of the National Library of Medicine (NLM), dated 5/15/23, indicated but was not limited to:- Gauze (a fabric dressing that does not stick to the skin) dressings to be changed every 48 hours, and transparent semi permeable dressings every seven days.(https://pmc.ncbi.nlm.nih.gov/articles/PMC8765739/) Resident #56 was admitted to the facility in December 2025 with diagnoses including acute osteomyelitis (an infection in a bone) of the left ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA, Staphylococcus aureus bacteria that are resistant to treatment with one of the semi-synthetic penicillin), and cutaneous abscess (painful, pus-filled pocket under the skin, usually caused by a bacterial infection) of the left foot. Review of the Minimum Data Set assessment, dated 12/23/25, indicated Resident #56 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and he/she had a central line and was receiving intravenous (IV) antibiotics. Review of Resident #56's current Physician's Orders indicated but was not limited to:- Dressing: PICC 24 hours after insertion, then weekly and as needed. One time a day every 7 days and as needed, dated 12/18/25. During an interview with observation on 1/12/26 at 9:02 A.M., the surveyor observed Resident #56 sitting in his/her wheelchair with a PICC line in his/her right upper arm. There was a 2-centimeter (cm) x 2 cm split gauze over the insertion point of the PICC line covered with a transparent dressing, undated. Resident #56 said he/she had received IV antibiotics through his/her PICC line twice daily and the dressing to the PICC line was last changed last week. Review of Resident #56's January Treatment Administration Record (TAR) indicated the PICC line dressing was last changed on 1/9/26. Further review of medical record failed to indicate no as needed dressing changes had been documented. On 1/12/26 at 2:43 P.M. and 1/13/26 at 8:42 A.M., the surveyor observed a transparent dressing over Resident #56's PICC line dressing with a 2 cm x 2 cm gauze covering the insertion point of the PICC line. During an interview on 1/13/26 at 11:04 A.M., Nurse #5 said Resident #56 had an order to change their PICC line dressing every seven days and as needed. She said she had last changed Resident #56's PICC line dressing on 1/9/26 as indicated on his/her treatment sheet and covered the insertion site with gauze. She said she was not sure if there was a difference in the frequency a PICC line dressing would need to be changed depending on if it was covered with gauze or not. During an interview on 1/13/26 at 1:46 P.M., the Director of Nursing said if a resident had a PICC line dressing it would need to be changed weekly or more often if soiled. She said if the insertion site of the PICC line was covered with gauze it would need to be changed every 48 hours because you cannot assess the insertion site if it is covered.

Based on interview and record review, the facility failed to notify the Resident's Physician or Nurse Practitioner about a medication error to re-evaluate the potential need to alter the treatment plan for one Resident (#56), from a total sample of 28 residents. Specifically, the facility failed to notify the Physician or Nurse Practitioner of Resident #56 receiving five doses of two antibiotics.Findings include:Review of the facility's policy titled Adverse Consequences and Medication Errors, last revised June 2025, indicated but was not limited to:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.-Examples of medication errors include:-unauthorized drug- a drug administered without a provider's order.-Promptly notify the provider of any significant error or adverse consequences. Resident #56 was admitted to the facility in December 2025 with diagnoses including acute osteomyelitis (an infection in a bone) of the left ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA, Staphylococcus aureus bacteria that are resistant to treatment with one of the semi-synthetic penicillin), and cutaneous abscess (painful, pus-filled pocket under the skin, usually caused by a bacterial infection) of the left foot.Review of the Minimum Data Set assessment, dated 12/23/25, indicated Resident #56 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and he/she was receiving intravenous (IV) antibiotics.During an interview on 1/12/26 at 9:02 A.M., Resident #56 said he/she went to an appointment on 1/9/26 and was told by the doctor to continue their IV antibiotics for two more weeks then switch to oral antibiotics.Review of Resident #56's Physician's Orders indicated but was not limited to:-Ceftriaxone Sodium (antibiotic) Injection Solution Reconstituted 2 grams (gm) intravenously in the morning for osteomyelitis until 01/23/26, dated 1/9/26-Daptomycin (antibiotic) Intravenous Solution Reconstituted 575 milligrams (mg) intravenously in the evening for osteomyelitis until 1/23/26, dated 1/9/2026-Doxycycline (antibiotic) Capsule 100 mg, give 1 capsule by mouth two times a day for osteomyelitis for 14 days. Start 1/24/26, dated 1/13/26-Amoxicillin-Pot Clavulanate (antibiotic) tablet 875-125 mg, give 1 tablet by mouth two times a day for osteomyelitis for 14 days. Start 1/24/26, dated 1/12/26 Review of Resident #56's discontinued Physician's Orders indicated but was not limited to:-Doxycycline Capsule 100 mg, give 1 capsule by mouth two times a day for osteomyelitis for 14 days until 1/23/26. Start date 1/10/26 discontinue date 1/12/26-Amoxicillin-Pot Clavulanate tablet 875-125 mg, give 1 tablet by mouth two times a day for osteomyelitis for 14 days until 1/23/26. Start date 1/10/2026 discontinue date 1/12/26 Review of Resident #56's Physician's Consult, dated 1/9/26, indicated but was not limited to:-Continue Ceftriaxone and Daptomycin until next visit-Follow up in two weeks Review of Resident #56's January Medication Administration Record indicated five doses of oral Doxycycline and Amoxicillin-Pot Clavulanate were administered to him/her on the following days and time:-1/10/26 at 9:00 A.M. and 9:00 P.M.,-1/11/26 at 9:00 A.M. and 9:00 P.M., and-1/12/26 at 9:00 A.M. During an interview on 1/13/26 at 10:57 A.M., Nurse Practitioner (NP) #1 said she was not aware Resident #56 had received five doses of Doxycycline and Amoxicillin-Pot Clavulanate orally. She said Resident #56 was only supposed to be on IV antibiotics and either she, the Physician, or the other two NPs should have been notified of the error. During an interview on 1/13/26 at 11:28 A.M., Unit Manager #4 said she discovered the medication error on 1/12/26 and she called the Consulting Physician's office to clarify the antibiotic order. She said Resident #56 was supposed to continue IV antibiotics and was not supposed to receive Doxycycline and Amoxicillin-Pot Clavulanate. She said she discontinued the Doxycycline and Amoxicillin-Pot Clavulanate but did not call or notify Resident #56's Physician or NP, but she should have notified them. During an interview on 1/13/26 at 1:46 P.M., the Director of Nursing said she was not aware of the medication error until today (1/13/26). She said when a medication error is identified the Physician or NP should be notified because consulting physicians can make recommendations but cannot give orders for medication changes.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #2), the Facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.Findings include:Review of the Facility Policy titled Baseline Care Plans, dated as last revised 3/2022, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.The Policy further indicated the baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents.1) Resident #1 was admitted to the Facility in 9/2025, diagnoses include respiratory failure, pneumonia, chronic obstructive pulmonary disease and is oxygen dependent.Review of Resident #1 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;-Acute on chronic respiratory failure, dependent on four (4) liters (l) of oxygen;-Average Volume-Assured Pressure Support (AVAPS) use at night;-Pneumonia with antibiotic use;-Acute heart failure; and-Subcutaneous anticoagulation.Review of Resident #1's admission Resident Evaluation, dated 09/09/25, indicated he/she had an open area to his/her coccyx requiring a treatment.Review of Resident #1's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented to address these areas of concern within 48 hours of his/her admission.2) Resident #2 was admitted to the Facility in 11/2025, diagnoses include acute respiratory failure with hypoxia, dependent on supplemental oxygen related to chronic obstructive pulmonary disease, and congestive heart failure.Review of Resident #2 Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;- Chronic respiratory failure, dependent on two (2) l of oxygen;-Frequent falls; and-Constipation.Review of Resident #2's Medical Record indicated that there was no documentation to support that Baseline Care Plans were developed and implemented, or that the Comprehensive Care Plans addressed these areas of concern were in place within 48 hours of admission.During an interview on 11/26/25 at 1:42 P.M., the Unit Manager said that she was not aware that Resident #1 did not have a completed baseline care plan and said that it was her responsibility to complete the baseline care plans.The Unit Manager said that as a team the management staff is to review a new admission chart the next day at morning meeting to ensure that the baseline care plans are completed.During an interview on 11/26/25 at 2:18 P.M., the Assistant Director of Nurses (ADON) said that she was unaware that Resident #1 and Resident #2's baseline care plans had not been completed.The ADON said that each disciple should be initiating their individual baseline care plan and that the Unit Manager and Night Shift Supervisor should be checking for completion.During an interview on 12/26/25 at 3:32 P.M., the Director of Nurses (DON) said that she was not aware of Residents #1 and #2 were missing their baseline care plans upon admission.The DON said that it is the Facility's expectation that the admitting nurse is to initiate the resident's baseline care plan and said, along with the other disciplines complete the Baseline care plan within 48 hours of admission.

Based on records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they maintained Resident #4's right to privacy and confidentiality related to his/her Protected Health Information (PHI), when one of Resident #4's provider progress notes, which contained (PHI) was included in another resident's discharge paperwork and the Facility only became aware after the discharged residents' family member called and notified the Facility.Findings include: Review of the Facility Policy titled Use and Discloser of Health Information, dated as last revised 09/12/2013, indicated that the Center respects the importance of its residents' personal privacy, and understands the sensitive nature of its residents' health information. The Policy further indicated that the Center also recognizes that Federal and State laws require that individually identifiable health information must be safeguarded against improper use or disclosure. During a telephone interview on 11/25/25 at 10:08 A.M., Family Member #1 said that on 09/14/25, Resident # 1 was discharged from the facility, she took him/her home and said when she read his/her Discharge Paperwork, she noticed that there was another resident's name in Resident #1's notes from the Facility. Family Member #1 said she called the Facility to inform them of a Health Insurance Portability and Accountability Act (HIPPA) Violation.Resident #1 was admitted to the Facility in 9/2025, diagnoses include respiratory failure, pneumonia, chronic obstructive pulmonary disease and is oxygen dependent.Review of Resident #1's discharge paperwork, dated 09/14/25, indicated that his/her Facility Provider had entered an admission Physician's Note for Resident #4 into Resident #1's Medical Record.The Note listed Resident #4 (by name) and included, but was not limited to, his/her medical diagnoses, hospital stay information, physical exam, code status, current clinical and medical status, vital signs, laboratory results, and medications.Resident #4 was admitted to the Facility in 9/2025, diagnoses include fall from a ladder with subsequent falls, rib fractures, a left clavicle fracture, and alcohol use disorder.During an interview on 11/26/25 at 12:14 P.M, Nurse #1 said that Family Member #1 had called the Facility shortly after she had taken Resident #1 home on [DATE]. Nurse #1 said that Family Member #1 told her that they had sent Resident #1 home with the wrong discharge paperwork and that it was a HIPPA violation. Nurse #1 was she was unaware that Resident #1's Provider had inadvertently written a progress note in the wrong medical record and said that she had not noticed it in his/her discharge paperwork.During an interview on 11/26/25 at 1:42 P.M., the Unit Manager said that she was aware that Resident #1's Family Member had called the Facility to report that another resident's (Resident #4) information was sent home with Resident #1. The Unit Manager said that she does not remember reporting it to anyone and said that she did not know she had to inform Resident #4 of the breach in privacy issues.During an interview on 11/26/25 at 2:18 P.M., the Assistant Director of Nurses (ADON) said that she was not aware (until after Resident #1 had been discharged ) that Resident #1 had received some personal medical information that was for Resident #4 in his/her discharge paperwork. The ADON said that she does not recall informing Resident #4 of the error that had been discovered.During an interview on 11/26/25 at 3.32 P.M., the Director of Nurses (DON) said that she was unaware (until date of survey 11/26/25) that the Facility had some of Resident #4's private health information in Resident #1 paperwork upon discharge.The DON said that she should have been made aware of the issues when she had returned from vacation and the event should have been investigated when the complaint was given.The DON said that it is the Facility's expectation that Providers double-check that medical record entries are for the intended Resident being documented on prior to entering the information into a Resident's record and that the party involved with the privacy breach needs to be informed of the error in a timely manner.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who had been assessed as requesting the use of bilateral side rails upon admission, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when physician's orders were not obtained by nursing for the use of bilateral side rails. Findings include: Review of the Facility Form titled Informed Consent for Use of Bed Rail, undated, indicated under the section of Additional Comments, a blank box precedes the statement, Physician's Order has been obtained, including medical symptom/condition. 1) Resident #1 was admitted to the Facility in January 2025, diagnoses include metastatic colon cancer, history of falls, change in mental status, pulmonary emboli (blood clot in the lung), and ascites (abnormal buildup of fluid in the abdomen) with the need for a pleurx- drain (tunneled indwelling peritoneal catheter to manage small amounts of ascites). Review of Resident #1's Informed Consent for Use of Bed Rails, dated 01/12/25, indicated that it had been recommended that two (2) half partial rails at all times when in bed. The Bed Form had been signed by Resident #1 voluntarily consenting to the recommendation, however, the box indicating that a Physician's Order had been obtained was left blank. Review of Resident #1's Physician's Orders, dated 01/12/25 through 01/18/25, indicated that there was no documentation to support nursing had obtained a physician's order for his/her use of bilateral half side rails. 2) Resident #2 was admitted to the Facility in January 2025, diagnoses include a fall with a right lower leg fracture, anxiety, depression, chronic pain, and Amyotrophic Lateral Sclerosis (ALS, progressive neurological disease affecting nerve cells in the brain and spinal cord). Review of Resident #2's Informed Consent for Use of Bed Rails, dated 01/03/25, indicated that it had been recommended two (2) half partial rails at all times when in bed. The Bed Rail Form had been signed by Resident #2 voluntarily consenting to the recommendation and the box indicating that a Physician's Order had been obtained had been checked off. However, review of Resident #2's Physician's Orders, dated 01/03/25 through 04/09/25, indicated that there was no documentation to support nursing had obtained a physician's order for his/her use of bilateral half side rails. During a telephone interview on 04/16/25 at 3:46 P.M., Nurse #2 said that she thought the Consent to use Side Rails Form was the Physician's Order and said she did not realize there was a place on the Form indicating that a Physician's Order had to be obtained. During a telephone interview on 04/09/25 at 2:32 P.M., Nurse #1 said she was aware that resident's utilizing side rails must have a Physician's Order however, said she was not aware Resident #1 did not have a Physician's Order to utilize side rails. During an interview on 04/09/25 at 4:04 P.M., the Director of Nurses (DON) said she was unaware that Resident #1 and #2, did not have a Physician's Order to utilize bilateral side rails. The DON said that it is the Facility's expectation that any resident requiring or requesting the use of side rails, the nurse must obtain consent from the resident and/or responsible party and a Physician's Order must be obtained prior to side rail use.

Based on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Dispose of oral medications that were no longer stored in their original dispensing systems in two of five medication carts reviewed; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of three medication room refrigerators reviewed. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: -Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. -Controlled substances (listed as Schedule II-IV of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected (e.g. medications for direct administration). 1. On 10/8/24 at 7:20 A.M., the surveyor reviewed the Aster Unit medication cart with Nurse #6 and observed a variation of approximately 25 loose oral medication tablets/capsules stored on the bottom of the third and fourth drawers. The medications were not disposed of when no longer stored in their original dispensing systems and loose in the drawers. During an interview on 10/8/24 at 7:20 A.M., Nurse #6 said sometimes the pills come out over the drawers when the nurses punch them out from their dispensing packs. She said all nurses are supposed to check the drawers for loose pills and said they were not stored properly and should have been disposed of. Nurse #6 said she was not able to identify what the loose medications were. On 10/8/24 at 7:46 A.M., the surveyor reviewed the [NAME] Unit team 1 medication cart with Nurse #7 and observed a variation of approximately 15 loose oral medication tablets/capsules stored on the bottom of the fourth drawer. The medications were not disposed of when no longer stored in their original dispensing systems and loose in the drawers. During an interview on 10/8/24 at 7:46 A.M., Nurse #7 said there should not be any loose pills in the drawers and they should have been disposed of but weren't. She said pills can fall into the drawers when nurses are popping them, but all nurses are responsible for checking for them. During an interview on 10/8/24 at 1:43 P.M., the Director of Nursing (DON) said if the nurse pops a pill out of the card and the pill falls into the drawers then the nurse should dispose of it immediately. She said all the loose pills should have been destroyed. 2. On 10/8/24 at 7:55 A.M., the surveyor reviewed the [NAME] Unit medication storage room with Unit Manager (UM) #3 and observed a controlled substance metal storage box on a shelf inside the medication refrigerator. The box was locked but was not permanently affixed to the shelf. The refrigerator was not locked. The surveyor was able to remove the box from the refrigerator and place it on the counter. Contents were heard inside. During an interview on 10/8/24 at 7:55 A.M., UM #3 said he didn't know what was in there and did not have a key to open it. UM #3 said he would ask Nurse #7 to unlock it. On 10/8/24 at 8:07 A.M., the surveyor reviewed the controlled substance storage box with Nurse #7 and observed two packages of Ativan (lorazepam/schedule IV-controlled substance, treats anxiety)/Benadryl (diphenhydramine, antihistamine) 1 milligram (mg)- 12.5 mg/milliliter (ml) gel tabs (30 total) stored inside labeled with a resident's name. During an interview on 10/8/24 at 8:07 A.M., Nurse #7 said she didn't know if the box was supposed to be permanently affixed. During an interview on 10/8/24 at 1:40 P.M., the DON said the box should have been permanently affixed to the inside of the medication refrigerator.

Based on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Have voiced grievances investigated and addressed, for one Resident (#287), out of two residents investigated, who had repeatedly voiced concerns over call light answering times; 2. Provide one Resident (#238), out of a total sample of 25 residents, with a resolution to their grievance either in writing or by discussion once the grievance had been resolved; and 3. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievances/Complaints, Filing, dated as revised April 2017, indicated but was not limited to the following: - Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff - the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or resident representative - a copy of the grievance/complaint procedure is posted on the resident bulletin board - grievances or complaints may be submitted orally, in writing or filed anonymously - upon receipt of a grievance the grievance officer will review and investigate the concern and submit a written report of such findings within 5 working days to the administrator - the administrator has delegated responsibility of grievance and/or complaint investigation to the grievance officer - the grievance officer, administrator and staff will take immediate action to prevent further potential violations or resident rights while the alleged violation is being investigated - the resident or person filing the grievance will be informed verbally or in writing of the findings of the investigation and the actions that will be taken to correct the identified problems - results of all grievance files will be maintained on file for a minimum of three years from the date of issuance of the grievance decision 1. Resident #287 was admitted to the facility in September 2024 for short term rehabilitation with diagnoses including: displaced bimalleolar fracture of the right lower extremity (a severe injury to the ankle when both the medial and lateral malleolus bones are broken and the ankle is dislocated), fall, and chronic obstructive pulmonary disease (lung disease that causes difficulty breathing and restricts airflow). Review of the Minimum Data Set (MDS) assessment, dated 9/24/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 10/8/24 at 5:14 P.M., the Director of Nurses (DON) and Administrator said they were made aware of Resident #287's concern when his/her family member posted a Google review online. The DON said she spoke with the Resident, who was still in the facility at that time, and did not discharge until the following day. The DON said the Resident's concerns were vague but they completed a grievance and investigation based off the Google review and Resident interview. During an interview on 10/9/24 at 10:38 A.M., via telephone, Resident #287 said he/she was admitted to the facility for a fluff and buff and only expected to remain at the facility for rehabilitation services for approximately four to five days. However, he/she contracted COVID-19 while at the facility which slowed their rehab progress and extended their stay. The Resident said he/she had voiced concerns numerous times about things he/she was seeing with other residents that they felt was neglectful and also the long call wait times. He/she said there were times they felt they waited on the call light for more than an hour and would report the concern to staff but felt unheard and staff would tell him/her those allegations were untrue. He/She said they attempted to voice their grievances with the Ombudsman and was told he/she would need to contact the Department of Public Health (DPH) to voice their concerns directly through the complaint line. Resident #287 said he/she also spoke to someone else in management once about call lights not being answered for long periods of time, but no one ever followed up with him/her on an investigation, outcome, or resolution. Resident #287 said at one point, he/she had a conversation with the DON but it left him/her frustrated because he/she said the DON asked them, What would you do to fix this situation? and that made him/her feel that the concerns were not being heard, looked into, or taken seriously. Resident #287 said he/she never received any resolution to any concerns or grievances he/she brought forward and he/she felt the call light wait times continued to be long. The Resident said just prior to discharge he/she had a [NAME] conversation with the DON about staff not helping him/her or other residents and the call light wait times being too long. The Resident said the DON replied to him/her, What would you do if you were me?. Resident #287 still felt the concerns were not being taken seriously or that the facility was receptive to the information so their niece decided to post a Google review of the experience. Resident #287 said he/she was not aware of whether a grievance form was ever completed because the concerns seemed ongoing without resolution. The Resident said they decided, after they discharged , to contact DPH. During an interview on 10/9/24 at 11:38 A.M., via telephone, Family Member #1 said they personally reached out to the DON after Resident #287 informed them their concerns were not addressed. She said the DON did not seem receptive to hearing the concerns or why she had reached out and told her that no information could be disclosed to her since the Resident is his/her own person without the expressed permission of the Resident. She said she finally just informed the DON that the call lights were not answered timely throughout the entirety of the Resident's stay and those issues went unresolved and because she felt everything was being dismissed, she decided to write the Google review which occurred the day prior to her family member's discharge from the facility. Review of the facility's Grievance Book for 2024 failed to indicate a grievance was formulated prior to 9/15/24 for Resident #287's concerns. During an interview on 10/9/24 at 4:29 P.M., the DON said she did take a call from Resident #287's family member and received some vague concerns feeling the unit and atmosphere were unsafe and residents were falling. She said she was not told about any call light wait time concerns, but did complete an investigation and grievance form on the vague concerns on or around 9/16/24 and interviewed the Resident for the investigation since the Resident was still at the facility. She said she did tell the family member she couldn't disclose any information on this Resident or any others without their permission. She said she felt the Resident was satisfied with the outcome of the investigation and was pleased they had made progress with rehab despite contracting COVID while at the facility and had no other concerns that were not addressed throughout the stay and said they felt safe in the facility. Staffing schedules were reviewed for the timeframe in which Resident #287 was in the facility and there was no significant deviance from the staffing baseline identified. Staff members were chosen for interview based on these schedules. During an interview on 10/10/24 at 10:14 A.M., Nurse #3 said he remembers Resident #287 and provided care to him/her including assessment, vital signs, medication administration and notifying the physician of a change in their respiratory condition resulting in obtaining new orders. He said Resident #287 seemed to expect that he/she would be a priority because they had COVID-19, but there were a few residents with COVID at that time and he prioritized them based on urgency of need. He said he explained this to the Resident and the Resident seemed displeased and complained of call light wait times. He said he believes this Resident's call light concerns were ongoing and he did not complete a grievance for these concerns and is unaware if anyone else had either. During an interview on 10/10/24 at 10:28 A.M., Nurse #2 said she remembers Resident #287 well and had interactions with them. She said she did receive verbal complaints from this Resident numerous times about call lights not being answered promptly, especially at night, and she did discuss it with the staff on all three shifts but felt after doing so the concern was untrue and therefore did not generate a grievance for the Resident. She said the Resident used the call light frequently for themselves and others and there was likely a higher attention on them and their light because of that and how vocal they were being but overall, she felt the Resident's call light was answered appropriately. During an interview on 10/10/24 at 10:51 A.M., Certified Nurse Aide (CNA) #3 said she provided care to Resident #287 and remembers them well. She said the Resident is what she would call a high complainer and even if something only took 10 minutes the Resident would tell her the wait time was too long. She said the Resident constantly complained to her about the call light not being answered timely and told her there were times it would take one to two hours to be answered even though she watched the call light be addressed within 5 minutes and the desired items received in maybe 15 minutes. She said the Resident would complain about the call light to her almost every day, but she never filled out a grievance and was unaware of what that was and said she would have no way of knowing if anyone else ever completed one either. Review of the progress notes in Resident #287's medical record indicated the Resident wished to speak with the DON on 9/17/24, but there were no prior notes indicating the Resident spoke to anyone regarding their concerns or that they had any unaddressed concerns or grievances pending. During an interview on 10/10/24 at 11:21 A.M., the DON said a grievance should have been formulated to address the Resident's concerns of long call wait times regardless of whether the staff felt the concerns were inaccurate. She said she did hear at some point that the Resident did have concerns with call light wait times and was unaware a grievance hadn't been completed as it should have been in accordance with the standard in an attempt to resolve the ongoing Resident issue. During an interview on 10/10/24 at 11:24 A.M., the Administrator said he is the grievance officer for the facility and shares the responsibility with the DON. He said if the Resident voiced a concern about poor call light response times a grievance should have been formulated, as good practice and to ensure the process was followed, but it appears one was not completed as it should have been. 2. Resident #238 was admitted to the facility in September 2024 with diagnoses including: acidosis (a condition in which the body fluids become too acidic), fall, multiple sclerosis, and adjustment disorder with anxiety and depressed mood. Review of Resident #238's BIMS score, dated 10/6/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/8/24 at 3:17 P.M., Resident #238 said he/she had voiced a concern about an interaction with a CNA in the early morning of either Monday or Sunday. Resident #238 said he/she voiced the concern to a staff member sitting at the desk, but did not know who that was and no one had brought it up again since then. Resident #238 said, Do you really think they would report that? I'm sure they didn't even write anything down. Review of the facility's Grievance Book on 10/8/24 failed to indicate a grievance was initiated or formulated for Resident #238. During an interview on 10/8/24 at 4:16 P.M., the DON and Administrator said they spoke with the Resident after the surveyor requested any additional incident reports or concerns for the Resident and the Resident did not report any concerns to them at that time. During an interview on 10/9/24 at 8:46 A.M., the DON said during her investigation she was made aware by one of the CNAs that Unit Manager (UM) #2 had been informed of the issue and UM #2 had told her a grievance was completed for the Resident although it had not been communicated to her prior and a copy was provided to the surveyor. During an interview on 10/9/24 at 9:09 A.M., UM #2 said on Monday night (10/7/24) she completed a grievance for Resident #238 regarding customer service and the staff not previewing the care cards prior to providing care to the Resident. She said she didn't pass the information to the DON because survey was occurring in the facility. She said she told the Resident she would look into his/her concern and educate the staff at the time she spoke with the Resident. She said the education on the grievance is not yet complete because it had just occurred. She reviewed the grievance form and education with the surveyor and said she should not have documented that the grievance was complete because the education wasn't done. She said she has not returned to Resident #238 and informed them of any follow up or resolution, even though she documented the grievance was taken and resolved on 10/7/24 and she communicated it to the Resident. During an interview on 10/9/24 at 9:31 A.M., the DON reviewed the concerns regarding the grievance process with the surveyor and reviewed the grievance form for Resident #238 from 10/7/24 and the staff education. She said the grievance form was not completed the way it is intended. Based on the education and the Resident saying he/she never spoke to anyone regarding a resolution, the grievance form was not completed correctly, the grievance was not resolved, and the process needed some work to ensure all staff understood the process and were on the same page. 36542 3. During a group meeting with Resident Council members on 10/9/24 at 12:30 P.M., the residents said they did not know where the grievance forms were located or how to find a grievance form to fill out on their own. One Resident said the forms were located by the elevator, the other residents replied that they mostly stayed on the second floor and did not go to the alcove where the elevators were located. On 10/9/24 at 1:10 P.M., the surveyor observed blank grievance forms in the alcove of the second-floor elevator. On 10/10/24 at 11:15 A.M., the surveyor observed the first floor (Ivy and Clover units) and the elevator alcove and was unable to locate any grievance forms available to residents. During an interview on 10/10/24 at 11:26 A.M., Unit Secretary #2 on the Ivy unit said she did not know where the grievance forms were located. During an interview on 10/10/24 at 11:28 A.M., Nurse #4 on the Ivy unit was able to locate blank grievance forms in a drawer at the nurses' station. She said residents could ask staff for a form if they needed one. During an interview on 10/10/24 at 11:35 A.M., CNA #3 on the Clover unit said the grievance forms were located inside of the nurses' station. During an interview on 10/10/24 at 11:37 A.M., Nurse #5 on the Clover unit said the grievance forms were in a hanging wall file inside of the nurses' station. During an interview on 10/10/24 at 2:30 P.M., the DON said the grievance forms are located on each unit behind the nurses' station and that they were not out and available for residents. She said they were located by the elevator on the second floor and should have been by the elevator on the first floor.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products and maintain safe and clean equipment in three of four nourishment kitchenettes. Findings include: Review of the facility's policy titled Food Preparation and Service, dated November 2022, indicated but was not limited to the following: - 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. - Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. - Food and nutrition services staff, including nursing services personnel, wash their hands before service food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. - Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Review of the facility's policy titled Food Receiving and Storage, dated November 2022, indicated but was not limited to the following: - Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. - 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. On 10/7/24 at 8:15 A.M., the surveyor made the following observations of the breakfast line service: - Three dietary aides and one cook were working on the service line. - Dietary [NAME] #1 used a gloved hand to plate bread and muffin products. The cook was also observed to use the same gloved hand to plate shredded cheese over eggs. The cook was not observed to change gloves at any time while serving the breakfast meal. - Dietary [NAME] #1 left the breakfast service line, attending to food products on the stove top and returning to the breakfast service line to plate food products without performing hand hygiene or changing gloves. On 10/9/24 at 7:30 A.M., the surveyor made the following observations of the breakfast line service: - At 7:35 A.M., Dietary Aide #1 returned from delivering a breakfast meal truck to a unit. Dietary Aide #1 returned to the end of the service tray line, re-arranging silverware on the tray, placing food covers on plates, and placing trays into the truck. Dietary Aide #1 did not perform hand hygiene prior to returning to the service line. - At 7:41 A.M., Dietary Aide #1 returned from delivering a breakfast meal tray to the Ivy Unit. Dietary Aide #1 did not perform hand hygiene prior to returning to the service line. - At 7:45 A.M., Dietary Aide #2 touched their hands to their ear and nose while working on the breakfast service line. Dietary Aide #2 continued to place coffee mugs, breakfast plates and condiments onto individual breakfast trays. Dietary Aide #2 did not perform hand hygiene after touching their face. - At 7:53 A.M., Dietary Aide #2 picked up a plastic bag from the floor underneath the breakfast service line. Dietary Aide #2 threw the plastic bag away and returned to the breakfast service line without performing hand hygiene. - At 8:03 A.M., Dietary Aide #1 touched the inside of the elevator door when returning from delivering a breakfast truck to a unit. Dietary Aide #1 returned to the breakfast service line and began pouring coffee. Dietary Aide #1 touched the inside of coffee mugs with their hands. Dietary Aide #1 did not perform hand hygiene prior to returning to the breakfast service line. On 10/9/24 at 11:20 A.M., the surveyor made the following observations during the lunch service line: - At 11:25 A.M., Dietary Aide #1 returned to the kitchen after delivering a tray to a unit. Dietary Aide #1 returned to the lunch service line without performing hand hygiene. - At 11:27 A.M., Dietary Aide #2 dropped coffee mug covers on the floor, picked them up and placed them in their apron. Dietary Aide #2 did not perform hand hygiene prior to returning to the lunch service line and service food products. - At 11:38 A.M., Dietary Aide #1 returned to the kitchen after delivering a tray to the unit. Dietary Aide #1 did not perform hand hygiene prior to returning to the lunch service line. During an interview on 10/9/24 at 1:45 P.M., the Regional Food Service Director (FSD) said dietary staff should be washing their hands when breaking from a task on the service line or leaving the kitchen. The Regional FSD said dietary staff should not be picking up items off the ground and returning to the service line without washing hands. The Regional FSD said utensils should be used when plating any type of prepared food product during a meal service line. 2. On 10/8/24 at 8:21 A.M., the surveyor made the following observations in the [NAME] Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food splatter covering the top/sides. On 10/8/24 at 8:28 A.M., the surveyor made the following observations in the Aster Unit nourishment kitchenette: - One Yoplait Peach yogurt wrapped in a paper towel in the back of the refrigerator with no resident name or identification. On 10/8/24 at 8:36 A.M., the surveyor made the following observations in the Ivy Unit nourishment kitchenette: - The inside of the microwave had food splatter/residue covering the top/sides. - A Trader Joe's Non-Dairy Oat Beverage carton was on the top shelf of the refrigerator with no resident name or identification. - A Ben and Jerry's Non-Dairy Cherry [NAME] Ice Cream was on the shelf of the freezer door with no resident name or identification. On 10/9/24 at 9:27 A.M., the surveyor made the following observations in the Clover Unit nourishment kitchenette: - Hard ice build-up with a brown residue noted to the bottom of the freezer. An individual popsicle provided by the facility was placed on top of the ice and residue. On 10/9/24 at 2:20 P.M., the surveyor made the following observations in the Ivy Unit nourishment kitchenette: - The inside of the microwave had food splatter/residue covering the top/sides. - A Trader Joe's Non-Dairy Oat Beverage carton was on the top shelf of the refrigerator with no resident name or identification. - A Ben and Jerry's Non-Dairy Cherry [NAME] Ice Cream was on the shelf of the freezer door with no resident name or identification. - The top of an apple juice carton on the bottom shelf of the refrigerator was covered in a brown liquid. The apple juice carton was dated as opened on 10/7/24. On 10/9/24 at 9:27 A.M., the surveyor made the following observations in the Clover Unit nourishment kitchenette: - Hard ice build-up with a brown residue noted to the bottom of the freezer. An individual popsicle provided by the facility was placed on top of the ice and residue. - The inside of the microwave had black and brown food splatter and residue to the top portion. On 10/8/24 at 8:21 A.M., the surveyor made the following observations in the [NAME] Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food splatter covering the top/sides. - Staff member heated up food in the microwave from a plastic container, and then left with the plastic container and lunch box. During an interview on 10/10/24 at 9:28 A.M., the Regional Food Service Director (FSD) said dietary staff are responsible for stocking the kitchenettes on each unit and for making sure items in the refrigerator and freezer are appropriately labeled and dated. The Regional FSD said equipment in the kitchenettes are cleaned and maintained by the maintenance department. The Regional FSD said the facility does not supply Trader Joe's or Ben and Jerry's products. Items brought in from outside of the facility should be labeled and dated with the resident's name. The Regional FSD said staff should not be using microwaves in the nourishment kitchenettes to heat up their food products.

Based on interview and document review, the facility failed to explain binding arbitration agreements and provide the Residents the right to fully review the agreement for three Residents (#238, #239, and #237), out of three sampled residents. Findings include: Review of the facility's policy titled Binding Arbitration Agreements, dated November 2023, indicated but was not limited to the following: - Residents are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements - Agreements are voluntary for the resident and are not required as a condition of admission or to receive care at the facility - Terms and conditions of the agreement are explained to the residents in a way that ensures his/her understanding to the agreement, including that the resident may be giving up their right to have a dispute resolved in a court proceeding (i.e., litigation) - The terms and conditions are explained in a manner that he/she can understand, taking into consideration the resident's primary language, literacy and preference for learning - After the agreements are explained the residents must acknowledge verbally and by signing - Residents are provided 30 days after signing to fully review and rescind any agreement not understood at the time of admission - Any facility personnel responsible for explaining the terms and conditions of binding arbitration agreements are trained to the specifics of this policy and its requirements During an interview on 10/7/24 at 8:21 A.M., the Director of Nurses (DON) said the facility offers arbitration agreements in the admission packet and residents have the option to opt out. She said the Admissions Director is responsible for the agreements and she would provide a list to the survey team of residents that had signed arbitration agreements. During an interview on 10/8/24 at 4:03 P.M., the Admission Director said she is responsible for arbitration but she is not the person that sits with the residents and explains the agreements; that is done by Unit Secretary (US) #1. She said she does not know what the content of those meetings are or what is discussed or how the arbitration is explained since she isn't there for the conversations and said the content is electronic and signed electronically. During an interview on 10/8/24 at 4:08 P.M., US #1 said she completes both the admission packets and arbitration agreements with all residents in the facility within a few days of their admission. She said she does not fully review the agreement or read the agreement for arbitration to the residents. She said she makes sure to tell them it is not required and that it means if they have an issue, they cannot sue the facility but instead have a meeting with a non-bias person for a settlement and resolution. She said once she tells them those two key parts, she asks them yes or no and has them electronically sign the documents. She said the documents are not available for the residents to read before signing because they are electronic and she does not provide them with a copy since they are not paper. A. Resident #238 was admitted to the facility in September 2024 for short term rehabilitation. Review of Resident #238's Brief Interview for Mental Status (BIMS) score, dated 10/6/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/10/24 at 9:32 A.M., Resident #238 said he/she was not sure what an arbitration agreement was. He/She was provided with a copy of the arbitration agreement they had signed and said they do not recall any of it being explained and they were never provided a copy before this interaction. He/She said, If I signed it within the pile of other things, then I guess it's too late. They said they were being discharged soon and felt since they were leaving, they didn't need to take any other action. B. Resident #239 was admitted to the facility in September 2024 for short term rehabilitation. Review of Resident #239's BIMS score, dated 9/30/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/10/24 at 4:22 P.M., Resident #239 said he/she worked with arbitration agreements throughout their career and is aware of what they are but was unaware that they had signed one at the facility. The Resident said the agreement was not explained to him/her and he/she was not given the opportunity to review the agreement or provided a copy. The Resident said had he/she realized he/she was signing an arbitration agreement he/she would not have signed it and he/she would ask their family to assist him/her in rescinding it since they were unaware and asked if there was anything they could do to get out of the agreement at this time. C. Resident #237 was admitted to the facility in October 2024 for short term rehabilitation. Review of Resident #237's BIMS score, dated 10/9/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/10/24 at 4:28 P.M., Resident #237 said he/she was asked to sign numerous things during the admission process but does not recall anyone explaining an arbitration agreement to them. He/She said they were not provided with a copy of the agreement for review and are aware of those documents and had used them in their work life in the past. The Resident said he/she would have requested a copy and not signed the document until they could have consulted with an outside resource, like their attorney or family. The surveyor provided Resident #237 with a copy of their signed arbitration agreement for review and the Resident said he/she had never seen the document before, had never reviewed it prior to now, and the agreement should not have been signed since it was not fully explained to him/her as required. During an interview on 10/11/24 at 9:12 A.M., the Administrator, who is newer to the facility, said residents should be receiving a folder with all their admissions paperwork and signed arbitration agreements inside. He said he was unaware things were not being explained and the residents were not receiving the documents for their review and that practice would require correction.

Based on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the recommended pneumococcal vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for five Residents (#117, #25, #113, #388 and #1), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated March 2023, indicated the following: -Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years Old, Complete Pneumococcal Vaccine Schedules: -PCV13 (pneumococcal conjugate vaccine) only at any age - give PCV20 (pneumococcal 20-valent conjugate) or PPSV23 (pneumococcal polysaccharide vaccine) >= 1 year later -PPSV23 only at any age - give PCV20 or PCV15 (pneumococcal 15-valent conjugate) >= 1 year later -PCV13 at any age and PPSV23 at >= [AGE] years - give PCV20 >= 5 years later Review of the facility's policy titled Pneumococcal Vaccine, revised October 2023, indicated but was not limited to the following: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of education shall be documented in the resident's medical record. -Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. -Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Resident #117 was admitted to the facility in June 2024 and was [AGE] years old. Review of the Physician's Orders indicated but were not limited to the following: -May have Pneumovax with consent (6/17/24) Review of the admission Influenza and Pneumococcal Vaccine Consent and Tracking Form, dated 6/17/24, indicated Resident #117 had refused the PCV13 and PPSV23 vaccine. The consent form did not include any other type of pneumococcal vaccine. Review of the Immunization Record indicated Resident #117 had received PPSV23 on 10/13/16 while in the community. Review of the medical record did not indicate Resident #117 had received information or education regarding the benefits and potential side effects of the pneumococcal vaccine to formulate an informed consent. 2. Resident #25 was admitted to the facility in October 2022 and was [AGE] years old. Review of the Physician's Orders indicated but were not limited to the following: -May have Pneumovax with consent (10/7/22) Review of the medical record did not indicate that an Influenza and Pneumococcal Vaccine Consent and Tracking Form was completed. During an interview on 10/11/24 at 9:47 A.M., the Unit Manager (UM) #3 said the admitting nurse, on admission, would have the resident or resident representative sign the Influenza and Pneumococcal Vaccine Consent and Tracking Form. The Infection Preventionist (IP) would follow up for the appropriate dosing. UM #3 reviewed Resident #25's medical record and said there was no evidence that an Influenza and Pneumococcal Vaccine Consent and Tracking Form had been obtained. Review of the Immunization Record indicated Resident #25 had received PCV13 on 4/21/16 while in the community. Review of the medical record did not indicate Resident #25 had received either the PCV20 or PPSV23 >= 1 year after the PCV13 vaccination per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose in the series, the provision of education to the Resident/representative related to the vaccine or offering and administration (if applicable) of the vaccine in accordance with CDC guidance and facility policy. 3. Resident #113 was admitted to the facility in February 2024 and was [AGE] years old. Review of the Physician's Orders indicated but were not limited to the following: -May have Pneumovax with consent (2/26/24) Review of the admission Influenza and Pneumococcal Vaccine Consent and Tracking Form, dated 2/26/24, indicated Resident #113 had refused the PCV13 and PPSV23 vaccine. The consent form did not include any other type of pneumococcal vaccine. Review of the Immunization Record indicated Resident #113 had received unknown pneumococcal vaccine prior to admission. No date indicated. Review of the medical record did not indicate Resident #113 had received information or education regarding the benefits and potential side effects of the pneumococcal vaccine to formulate an informed consent. 4. Resident #388 was admitted to the facility in September 2024 and was [AGE] years old. Review of the Physician's Orders indicated but were not limited to the following: -May have Pneumovax with consent (9/27/24) Review of the admission Influenza and Pneumococcal Vaccine Consent and Tracking Form, dated 9/27/24, indicated Resident #388 had refused the PCV13 and PPSV23 vaccine. The consent form did not include any other type of pneumococcal vaccine. Review of the Immunization Record indicated Resident #388 had received PCV13 on 1/12/23 while in the community. Review of the medical record did not indicate Resident #388 had received either the PCV20 or PPSV23 >= 1 year after the PPSV23 vaccination per CDC guidance. Review of the medical record did not indicate Resident #388 had received information or education regarding the benefits and potential side effects of the pneumococcal vaccine to formulate an informed consent. 5. Resident #1 was admitted to the facility in September 1998 and was [AGE] years old. Review of the Physician's Orders indicated but were not limited to the following: -May have Pneumovax with consent (9/28/18) Review of the medical record did not indicate that an Influenza and Pneumococcal Vaccine Consent and Tracking Form was completed. During an interview on 10/11/24 at 9:47 A.M., the UM #3 said the IP keeps a record of long-term residents' vaccine status and would alert him if a resident needs to receive a Pneumococcal vaccine. UM #3 reviewed Resident #1's medical record and said there was no evidence that an Influenza and Pneumococcal Vaccine Consent and Tracking Form had been obtained. UM #3 said he was not informed by the IP if Resident #1 needed a pneumococcal vaccine. Review of the Immunization Record indicated Resident #1 had received Pneumonia Dose #1, unspecified, on 2/3/14 while a resident at the facility. Review of the medical record did not indicate Resident #1 had received the pneumococcal vaccination per CDC guidance. Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended pneumococcal vaccine dose in the series, the provision of education related to the vaccine, and offering and administration (if applicable) of the vaccine in accordance with CDC guidance and facility policy. During an interview on 10/11/24 at 11:00 A.M., the Director of Nursing (DON) said she was the IP. The DON said the various pneumococcal vaccines were difficult to know when to offer and administer to residents. The DON said the pneumococcal vaccine status of residents had not been reviewed per the CDC guidelines. The DON said there had been no follow up on screening and eligibility or provision of education for Residents #117, #25, #113, #388 or #1 to receive or decline the most up to date pneumococcal vaccine.

Based on observation and interview, the facility failed to ensure residents in three of four dining areas had a dignified and homelike dining experience. Findings include: On 10/7/24 at 8:30 A.M., the surveyor made the following observations in the [NAME] Unit dining room: - Three residents were seated at tables in the dining area eating their breakfast meal on trays served at the table. - Covers for the plates were next to the residents filled with trash including milk cartons, coffee mug covers, and oatmeal bowl covers. - Three staff members were sitting in the back corner of the dining area, one of whom was on their phone. - A diathermy machine (a device used by physical and occupational therapy services to improve circulation, reduce swelling/inflammation, relax muscles/joints through electric currents to heat) was stored in the back of the dining area underneath the windows. On 10/8/24 at 8:11 A.M., the surveyor made the following observations in the [NAME] Unit dining room: - Three residents were seated at tables in the dining area eating their breakfast meal. - Two of the three residents were eating on trays served at the table. - One resident's meal was served off the tray but was noted to have the tray placed to the side of the meal on the table covered with trash including milk cartons, plastic wrap, and coffee mug covers. - All three residents were seated at different tables. Two residents were seated with their backs to one another facing the wall. One resident was seated facing the television which was playing a morning news show. - A diathermy machine was stored in the back of the dining area underneath the windows. On 10/8/24 at 12:08 P.M., the surveyor made the following observations in the [NAME] Unit dining room: - Eight residents were seated at tables in the dining area eating their lunch meal. - Seven of eight residents were eating on trays served at the table. - Two diathermy machines were stored in the back of the dining area underneath the windows. On 10/9/24 at 9:30 A.M., the surveyor made the following observations in the Clover Unit dining room: - Two residents were seated at tables in the dining area. - One resident was eating on a tray served at the table. The other resident in the dining area had finished their meal. - No staff were observed in the room during the mealtime. On 10/9/24 at 12:34 P.M., the surveyor made the following observations in the Clover Unit dining room: - Six residents were seated at tables in the dining area eating their lunch meal on trays served at the table. - Plate covers were next to residents filled with trash including milk cartons, plastic wrappers, and coffee mug covers. - Two residents were covered with blankets on their chest. All other residents were observed to have clothing protectors donned (on). On 10/9/24 at 12:39 P.M., the surveyor made the following observations in the Ivy Unit dining room: - Two residents were seated at tables in the dining area eating their lunch meal on trays served at the table. - Plate covers were next to the residents filled with trash including milk cartons, plastic wrappers, and coffee mug covers. - Four staff members were in the corner of the dining area. - Two of four staff members were completing electronic documentation on computers while having a casual conversation. - One staff member was peeling and eating an orange in the dining area. During an interview on 10/10/24 at 10:37 A.M., Certified Nursing Assistant (CNA) #1 said residents who eat in the dining area on the unit are to be served off the tray onto the table. CNA #1 said the trays are then removed from the dining area. CNA #1 said staff assigned to the dining area either help residents who require assistance with meals or supervise the dining area. During an interview on 10/10/24 at 10:44 A.M., Unit Manager (UM) #3 said residents eating meals in the dining area on the unit should be served their meals off the tray. UM #3 said sometimes the staff use placemats to serve the meal but should always serve meals on the table. Staff members are assigned to the dining area for supervision during mealtime. During an interview on 10/10/24 at 11:00 A.M., the Director of Nursing (DON) said residents eating in the unit dining areas typically require supervision during mealtime. The DON and the surveyor reviewed the observations made in the unit dining areas during the survey process. The DON said all staff should be supervising residents during mealtimes and not having social interactions or eating. The DON said all meals should be served off trays and onto the table in the unit dining areas during mealtimes.

Based on document review and interview, the facility failed to ensure two Residents (#238 and #237) were provided a summary of their baseline care plan meeting, out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, dated as revised March 2022, indicated but was not limited to the following: - a baseline care plan to meet the resident's immediate healthcare needs is developed for each resident within 48 hours of admission - the resident and/or their representative are provided a written summary of the baseline care plan that includes but is not limited to: the stated goals and objectives of the resident, a summary of medications and dietary instructions, and any services and treatments to be administered - provision of the summary to the resident and/or representative is documented in the medical record A. Resident #238 was admitted to the facility in September 2024 with diagnoses including: acidosis (a condition in which the body fluids become too acidic), fall, multiple sclerosis, and adjustment disorder with anxiety and depressed mood. Review of Resident #238's Brief Interview for Mental Status (BIMS) score, dated 10/6/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/8/24 at 3:15 P.M., Resident #238 said he/she was aware of the team goals for him/her to return home and certain things that needed to be accomplished but was never provided with a summary of that meeting or what was discussed to keep him/her on track. Resident #238 said he/she did not know what a care plan was and never received a copy of one. B. Resident #237 was admitted to the facility in October 2024 with diagnoses including: hypertensive emergency (a medical emergency in which the blood pressure increases suddenly and severely and can lead to life threatening organ damage), chronic obstructive pulmonary disease (lung disease that causes difficulty breathing and restricted airflow), and diabetes mellitus. Review of Resident #237's BIMS score, dated 10/9/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 10/8/24 at 9:29 A.M., Resident #237 said he/she had not been offered a summary of his/her goals of care or what the plan was while he/she resided in the facility and he/she did not have anything to refer to on what the facility felt the plan was. He/She said this document would be helpful so he/she would have more details and know better what questions to ask and discuss. Review of the medical record for Resident #237 on 10/9/24, including the assessment forms, progress notes and admissions evaluation, failed to indicate Resident #237 was provided a summary of their baseline care plans or initial interdisciplinary meeting. During an interview on 10/9/24 at 2:33 P.M., Social Worker (SW) #1 and SW #2 said the process for base line care plan meeting is for the team to meet with newly admitted residents Monday through Friday after morning meeting and then the case manager (CM) writes a note under the forms section called initial care conference meeting. They said the residents are not offered any summary or documents unless they specifically ask for something and then they will print out whatever they request, but there is no official process in which they are offered any summary or synopsis of the event. During an interview on 10/9/24 at 2:33 P.M., the Director of Nurses (DON) reviewed the medical record for Residents #237 and #238, including the assessment forms and progress notes, and said there was no documentation or evidence indicating either Resident was provided a summary of their baseline care plans or initial interdisciplinary meeting. She said the CM had been on vacation the previous week and the SW was supposed to ensure notes were put in the system for all the meetings held and they had not occurred yet. She said she has attended some meetings in the past, but it is not part of her daily routine. She said there is no form or summary that is routinely offered to the residents following those meetings that she is aware of but the facility would provide the residents with any documents if they were requested. She couldn't provide an explanation for the lack of a baseline care plan summary being offered. During an interview on 10/10/24 at 9:21 A.M., the CM said after the meetings are held, the group discusses the individual residents and a note is written which is a pre-formulated form in the system with a check box to indicate the residents participated and are in agreement with the care plans. She said however there is no summary provided and she was not aware that was part of the regulatory requirement.