Every finding on record at Care Village at Mattapan

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required 1) anticonvulsant medication for epilepsy (seizure disorder) and 2) an anticoagulant (blood thinner) for a newly diagnosed deep vein thrombosis (DVT, blood clot), the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility, his/her medication orders were not accurately reconciled by nursing resulting multiple missed doses of both medications. Resident #1 was observed experiencing seizure activity, was transported to the Hospital Emergency Department for evaluation and was admitted for treatment.Findings include:Review of the Facility Policy titled Medication Reconciliation and Management, undated, indicated medication reconciliation reduces adverse medication events and assists the resident to get the most effect from their medication.The Policy indicates to review and document all medications the resident is taking and compare the list to the hospital discharge summary. Identify any potential medication adverse effects, significant drug interactions, duplication, and non-adherence with drug therapy and notify the physician with any medication discrepancies. Review of the Facility Policy titled Adverse Consequences and Medication Errors, undated, indicated a medication error is defined as the preparation or administration of drugs or biologics which is not in accordance with physician's orders, manufactures specifications, or accepted professional standards.The Policy indicated a medication error includes an omission, a drug that is ordered but not administered.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/22/26, indicated (per the Hospital Discharge Summary) Resident #1 was supposed to be administered an anticonvulsant (used to prevent seizures) medication as well as maintained on a tapered dose of an anticoagulant (blood thinner). The Report indicated Resident #1's anticonvulsant (Keppra) had not been transcribed into the Point Click Care (PCC, Facility's electronic record) system upon readmission leading to a significant medication error.The Report further indicated upon investigation, a second transcription error had been identified, and that Resident #1's anticoagulant (Eliquis) had been transcribed incorrectly.Resident #1 was admitted to the Facility in July 2025, diagnoses include epilepsy (seizure disorder), toxic encephalopathy, Cerebral Vascular Accident (CVA), and gastric ulcer with a gastrostomy (tube inserted into the stomach to provide nutrition) in place. 1) Review of Resident #1's Hospital Discharge (DC) Summary, dated 04/11/26, indicated that he/she was to receive the following;-Keppra 1,500 milligrams (mg) via gastrostomy tube twice daily (BID)Review of Resident #1's Physician's Orders, dated 04/11/26 through 04/20/26, indicated there was no documentation to support his/her orders for Keppra had been transcribed upon readmission.Review of Resident #1's Medication Administration Record (MAR), dated 04/11/26 through 04/20/26, indicated there was no documentation to support his/her Keppra had been administered for ten (10) days (for a total of 18 missed doses).Review of Resident #1's Nurse Progress note (written by Nurse #1), dated 04/20/26, indicated he/she was observed having a seizure for more than 30 minutes, non-stop. The Note indicated Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she presented with breakthrough seizures in the setting of not receiving his/her seizure medication (Keppra) at the Facility. 2) Review of Resident #1's Hospital DC Summary, dated 04/11/26, indicated that he/she was to receive the following;-starting 4/11/26 - nursing to administer Eliquis ten (10) mg by mouth BID for four (4) days (through 4/15/26); -starting 4/16/26 - nursing was to administer Eliquis five (5) mg by mouth BID for 90 days, for a newly diagnosed right upper extremity deep vein thrombosis (DVT).Review of Resident #1's MAR, dated 04/11/26 through 04/15/26, indicated he/she was administered Eliquis 10 mg by mouth BID for 4 days, as ordered.Review of Resident #1's Pharmacy Medication Review, dated 04/13/26, indicated nursing staff should ensure Eliquis 5 mg by mouth BID physician's order is entered [into the electronic medical record, PCC] prior to the start date [4/16/26] to prevent a delay in care.However, further review of Physician's Orders, indicated there was no documentation to support his/her Eliquis 5 mg (starting 04/16/26) BID for 90 days had been transcribed upon Resident #1's readmission. Review of Resident #1's MAR dated 04/16/26 through 04/20/26, indicated there was no documentation to support his/her Eliquis 5 mg by mouth BID had been administered for 5 days (for a total of nine (9) missed doses).During an interview on 05/13/26 at 4:32 P.M., Nurse #1 said on 04/11/26, he was Resident #1's nurse and was responsible for his/her medication reconciliation upon his/her readmission. Nurse #1 said he was having difficulty entering Resident #1's medications into PCC and that he forgot to go back to complete the transcription of his/her Keppra ordersNurse #1 said Resident #1's Keppra was never transcribed, ordered or administered despite being a physician's order on his/her Hospital DC summary and only one of the Eliquis orders had been entered into PCC.Nurse #1 said he did not reconcile Resident #1's medications with another nurse and was not aware errors were made during reconciliation until the Director of Nurses (DON) made him aware of the significant medication errors. During an interview on 05/13/26 at 2:37 P.M., the Nursing Supervisor said that she was not aware of the significant transcription medication errors made upon Resident #1's readmission until the Hospital called to inform the Facility of their findings.The Nursing Supervisor said Resident #1's Keppra was not transcribed onto his/her MAR upon his/her readmission and only a portion of his/her Eliquis medication order had been transcribed leading to the significant medication errors.The Supervisor said there had been a paper Medication Reconciliation Form that was being used prior to the initiation of PCC (EMR system, about four years ago) but since the start of PCC, those paper forms were no longer being utilized to reconcile medications. During an interview on 05/13/26 at 3:40 P.M., the Director of Nurses (DON) said she was unaware of Resident #1's significant medication error until the Hospital called to inform her that his/her Keppra was missing from his/her facility medication list [sent with him/her by the facility at time of transfer to the Hospital].The DON said that she reviewed the original Hospital Discharge Summary from 04/11/26 and discovered there had been transcription errors with Resident #1's Keppra and Eliquis medications.The DON said that it is the Facility's expectation to have the admitting nurse review the resident's Hospital DC summary, any other sources of medications the resident had been receiving and enter the results into PCC.The DON said a second nurse must review the medication list printed from PCC and review for any errors. The DON said once verified, the admitting nurse will notify the provider of the medications, and any discrepancies will be documented onto their newly implemented medication reconciliation form and clarified by the provider. The DON said after medication reconciliation is completed, the next shift will review the reconciliation for potential errors and said she reviews all medication reconciliation forms as well as the Medical Director.On 05/13/26, the Facility staff presented the Surveyor with a plan of correction with an effective date of 04/30/26 that addressed the area of concern identified in this survey, as follows:A) Resident #1 was transferred to the Hospital Emergency Department for evaluation and was admitted .B) On 04/21/26, the Hospital Staff notified the DON regarding the omission of Resident #1's anticonvulsant medication (Keppra).C) On 04/21/26 and 04/22/26, Nurse #1 was educated by the DON regarding the Facility's policy and procedures related to medication reconciliation process.D) On 04/21/26 through 04/29/26, Nursing Staff were educated by the DON and/or designee regarding the Medication Reconciliation process, need to complete the newly implemented medication reconciliation form and the Electronic Medication Administration Record (EMAR) Medication Entry Process (which also included a written test and observations for competency conducted by the DON and/or designee).E) On 04/22/26 an Ad [NAME] Quality Assurance Performance Improvement (QAPI) meeting was held by Facility Management to review the incident, which included development and implementation of a Plan of Correction (POC).F) On 04/23/26, the [NAME] President (VP) of Clinical Services and the DON began a retrospective 30-day audit of all previous admissions and readmissions, during that time period.G) On 04/23/26 the V.P. of Clinical Services educated the DON regarding the timeliness of monitoring recommendations received from the Pharmacy.H) On 04/27/26 and 04/28/26, the Medical Director and primary Nurse Practitioner were educated by the DON and VP of Clinical Services regarding the Medication Reconciliation Process.I) An audit of all admissions and readmissions medication reconciliation forms will be completed 3 x week x 4 weeks, followed by weekly audits for the next 4 months or until compliance is achieved.J) The results of the audits will be brought to QAPI monthly x 3 months or until compliance is achieved.K) The DON and/or designee are responsible for overall compliance.

Based on interviews and records reviewed, the facility failed to implement an effective antibiotic stewardship program that included accurate and complete tracking and monitoring of antibiotic use. Specifically, the facility's antibiotic stewardship documentation was incomplete and did not accurately reflect residents with active antibiotic orders, and the facility was unable to demonstrate consistent monitoring, analysis, or reporting of antibiotic utilization in accordance with regulatory requirements.Findings include:Review of the facility policy titled Antibiotic Stewardship, dated as revised January 2024, indicated but was not limited to the following: -The commitment to oversee the use of antibiotics through a stewardship program is recognized as an integral to this facility's commitment to the highest quality of care and services. -The infection control preventionist will be considered the facility champion and antibiotic stewardship. -The monitoring of antibiotic use will be considered an integral and guiding the process changes tracking tools will include: *Monthly list of Antibiotics and prescribed each month as supplied by the provider pharmacy. *EMR (Electronic Medical Record) reports as available. *Manual chart review for resident symptomology. *Quarterly Antibiogram supplied by the laboratory vendor. *Participation in the antibiotic start reporting program Massachusetts facilities -Results from the data sources will be tracked over time to assess improvement in the need for continued changes and processes aimed at improvement.Review of the facility's Antibiotic Stewardship Program documentation, including monthly antibiotic line listings from February 2025 through January 2026, revealed the facility failed to implement an effective system for tracking and monitoring antibiotic use. The line listing documentation was incomplete and did not include start/stop dates, culture/diagnostic results and did not include an antibiotic time out to reassess the need for the antibiotics prescribed during the months of March 2025, April 2025, June 2025, July 2025, August 2025, September 2025, October 2025, and only one of two units were tracked. Further review indicated the month of May 2025 was missing and contained no documented infection control tracking or data. Review of physician order listing reports indicated multiple residents had active infections and were prescribed antibiotic therapy; however, these residents were not included on the facility's monthly line listings. Review of the electronic medical record indicated but not limited to, Resident #8 who was prescribed antibiotics for pneumonia which was not documented on the line listings and was receiving antibiotics without a documented clinical indication for use. The facility was unable to provide established criteria or guidelines for initiation of antibiotic treatment for pneumonia and failed to include tracking of antibiotic use, review of appropriateness, reassessment of continued need, and implementation of facility-specific prescribing criteria.During an interview on 2/18/26 at 1:25 P.M., the Infection Preventionist (IP) said she assumed the role in October 2025 and said she does not calculate or run monthly antibiotic utilization reports. The IP further said she was not aware of the antibiotic use within the facility and said she does not track antibiotic time-outs but will call the doctor if she feels it is necessary but not for all resident's receiving antibiotics. The IP said infections are discussed at the QAPI meeting with the Director of Nursing, but she does not report antibiotic usage criteria or infection control rates because she does not have that data. During an interview on 2/19/26 at 5:39 A.M., Nurse #5 said there are no line listing reports maintained at the nurse's station however she will document infections in a progress note and said she is not aware of any antibiotic stewardship line listings or reports.During an interview on 2/19/26 at 7:18 A.M., Consultant #2 said the antibiotic stewardship program needs to be tracked and reviewed to monitor the use of prescribed antibiotics and said she expects monitoring and reporting to be in place. Consultant #2 said the facility should be tracking and reporting the use of antibiotics and documenting infection control rates accurately.During an interview on 2/19/24 at 9:08 A.M., the Director of Nursing (DON) said she assumed the role recently and said nursing staff should be aware of the antibiotic stewardship program and said the facility should be tracking and reviewing the use of antibiotics as required monthly. The DON said the facility should have lab results, antibiotic usage reports and tracking data to review trends and to monitor for improvement. During an interview on 2/19/26 at 10:42 A.M., the Medical Director said the use of antibiotics within the facility should be monitored and evaluated for effectiveness and said he would expect the facility to review and report accurate information regarding antibiotics that are prescribed and not needed.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents on two of two units. Specifically, the facility failed to ensure resident rooms and common areas were maintained in good repair and sanitary condition and failed to consistently identify and correct environmental concerns through routine environmental rounds. Findings include: Review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, undated, indicated but was not limited to the following: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur. and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 14. Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloths moistened with and EPA - registered hospital disinfectant (or detergent). During environmental observations on the 2nd floor nursing unit, conducted on 2/17/26 at approximately 7:58 A.M., the surveyor observed multiple resident rooms with visibly soiled walls containing dark smudges and stains. Resident rooms and common areas were observed to have visible dirt and residue buildup. Floors throughout the unit, including resident rooms and nourishment rooms, were observed to have visible debris, dirt accumulation, and staining. room [ROOM NUMBER]: There were chunks of flooring missing and cracked in the room. Tiles were discolored with dark gray, black and rust colored building up inside the missing pieces. The door frame was scuffed and chipped. The top of the wall along the ceiling had a large dark brown rust colored substance splattered across the wall and ceiling and the wall had dark black scuffs and scratch marks across the middle section. room [ROOM NUMBER]: The bathroom door had dark scuff marks on the bottom right side near the wall, and the bathroom floor had dark brown and black buildup along the tiles. The exterior door to the hallway had gouges in the wood, chipped paint, and chipped laminate flooring with dark discoloration. room [ROOM NUMBER]: The light above the bed near window was flickering off and on. The bathroom vanity mirror was rusty along the inside edges and had broken metal and plastic pieces inside. The underside of the bed was coated in a dark rust colored dried substance and the wheels of the bed had white, dark, gray and rust build up along the sides. The bathroom floor had dark discolored tiles and dark buildup along the edges, and the bathroom door was chipped and dirty along the bottom. The bathroom door frame had dark brown and black scuffs with buildup along the edges. room [ROOM NUMBER]: The wall above the door separating two rooms had six large holes with missing and exposed white plaster and exposed yellow electrical cords. There was a piece of wood nailed to the floor under the bed with dark brown and black build up along the edge and top. The closet was missing a door. The bathroom floor had chipped tiles and paneling along the edge, and the door frame was chipped and cracked. Behind the toilet was dark stained floor tiles with cracks and chipped flooring. There was broken and exposed plaster under the hand sanitizing station There was missing and cracked tiles with exposed plaster under the paper towel dispenser. room [ROOM NUMBER]: The bathroom had missing and cracked tiles throughout and the tiles around the toilet had exposed plaster and chipped pieces. The floor was stained and had dark brown and black build up along the edges and throughout the bathroom. room [ROOM NUMBER]: The wall behind the television had multiple open holes and parts of the wall were unpainted with white plaster that was unfinished. room [ROOM NUMBER]: There was missing, chipped, cracked baseboard paneling near the closet, and along the corner of the wall. Chunks of plaster were missing from the wall and the trim around the bedroom door waws chipped and scuffed. The wall behind the bed near the window was unpainted and did not match the rest of the room. The baseboard heat had wires exposed and was missing covers. There was one electrical outlet with a missing cover that had exposed wiring hanging out of the wall. room [ROOM NUMBER]: There was a large piece of wood nailed to the floor located under the bed that had dark brown and black buildup around it. The paper towel dispenser in the bathroom was missing and the baseboard along the wall was chipped and peeling. room [ROOM NUMBER]: The bathroom sink had rust and brown buildup along pipes with loose covers hanging off the wall. The doorway had dark scuff marks along the wall, with chipped and loose paneling peeling off the floor near the closet. room [ROOM NUMBER]: The bathroom floor tiles had dark scuff marks, chipped tiles and dark buildup along the floor and bathroom door. The paper towel holder on the wall had a large rectangle cut out of plaster above the top. During environmental rounds on 2/17/26 at 12:23 P.M., the surveyor observed the following on the 1st floor nursing unit: -The shower room outside room [ROOM NUMBER] had broken and cracked tiles. The floor of the entry way was visibly soiled and the rubber base molding pulling away from tile. The shower curtain was tinged yellow in color. room [ROOM NUMBER]: The baseboard heater was rusted, and the windowsill was visibly dirty with debris. Shared Bathroom between rooms [ROOM NUMBERS]: There were stains on ceiling. A visitor in the room reported that the toilet seat was not secured to the toilet and swiveled around. The visitor said he had alerted staff, but it had been that way for months. room [ROOM NUMBER]: The ceiling was stained and the baseboard heater was visibly dirty and rusted. room [ROOM NUMBER]: There was a hole in the wall by the A side dresser. A resident said that he/she believed the hole was there from someone slamming the dresser into the wall. room [ROOM NUMBER]: There were patches of paint missing from the wall and the window curtains were hanging down from the window. room [ROOM NUMBER]: There were holes around doorframe leading to room [ROOM NUMBER]. room [ROOM NUMBER]: The windowsill was visibly dirty and soiled with dirt and debris. room [ROOM NUMBER]: There was a missing piece of flooring During an interview on 2/18/2026 at 11:09 A.M. the Director of Housekeeping said that he expects that resident rooms are cleaned daily and some rooms are selected for deep cleaning weekly. The Director of Housekeeping said that if residents refuse having their room cleaned, he expects staff to keep returning and trying until they can get in and clean the room. The Director of Housekeeping joined the surveyor and observed the dirty windowsill. The surveyor wiped her hand on the windowsill and showed the Housekeeping Director her palm was now visibly soiled and darkened with dirt. The Housekeeping Director said that the window as not clean, and it was not acceptable. During an observation on 2/19/26 at 6:12 A.M., the surveyor observed the following in the nourishment room on the 1st floor nursing unit: The floor was stained throughout the room and had dark brown and black build up along the edges and along the bottom of the cabinets. The floor in front of the refrigerator had numerous stains and dried spilled substances along the side and directly in front of the refrigerator and was sticky. The door frame had a brown dried liquid stain along the top. The door was cracked, chipped and had dark black and brown build up along the edges and across the bottom of the door. The inside cabinet had pink and brown stains on the bottom shelf. The microwave was placed on top of a broken piece of plaster that had brown-, yellow-, red- and rust-colored stains across the bottom. The microwave had cracked, chipped and peeling edges along the inside and dark brown build up located inside. During an observation on 2/19/26 at 5:58 A.M., the surveyor observed the following in the resident dining room located on the 1st floor: The wall had missing plaster and chunks of wall missing with scuffs and peeling baseboard along the edge. There were old food items, spills and trash located on top of three dining room tables. A dark liquid spill was observed on the floor and along one of the chairs. There were old pieces of food and numerous dried dark, and brown build up on the floor. There were crumbs along the edge of the room along with dead bugs and dust. During an interview on 2/19/26 at 7:49 A.M., the Director of Maintenance said he just started working at the facility a week ago and said there is a work service binder on each unit that is checked daily if staff find issues that need to be fixed withing the facility Review of the facility's environmental rounds documentation provided during the survey failed to indicate these observed environmental concerns were identified, addressed, or corrected. There was no documented evidence the facility had identified or implemented corrective actions to address the visibly soiled surfaces, damaged furniture, or flooring concerns observed during the survey. During environmental rounds on 2/19/26 at 9:09 A.M., accompanied by the Director of Maintenance and Consultant #1, the surveyor observed: room [ROOM NUMBER]: The bathroom floor tiles were discolored brown and dirty. The tiles surrounding toilet were cracked in several areas. The exterior sliding glass window had mold growing between panes which covered entire surface. room [ROOM NUMBER]: Approximately 12 floor tiles were cracked and crushed. There was a brown ceiling stain measuring approximately 2' x 2' near foot of Bed C. Approximately 12 areas of unpainted plaster repairs were on the walls. room [ROOM NUMBER]: The bathroom floor tiles were discolored brown, dirty and broken in several areas. There were floor tiles were missing behind the toilet. room [ROOM NUMBER]: The wall plate for television cable was cracked and exposed the electrical box. room [ROOM NUMBER]: In front of bathroom door were broken, dirty floor tiles. The bathroom floor was discolored brown and dirty. The bathroom cabinet interior was cracked and electrical box was exposed. The radiator cover was bent extensively and hanging from the radiator. room [ROOM NUMBER]: The bathroom sink was chipped and the drain was rusty. The floor tiles dirty. The radiator next to Bed B was missing approximately 4' of covers. The windowsill was covered in dirt and food stains. Under Bed B floor tile was crushed and measured approximately 4 x 4. Behind Bed B the electrical outlet was partially hanging from wall. room [ROOM NUMBER]: The ceiling by bathroom entrance had a bubbling, crumbing brown stain measuring approximately 2' x 2'. room [ROOM NUMBER]: The radiator covers by Bed B were covered in dirt and food stains and the cover was bent in several places. The bathroom floor tiles were discolored brown and dirty. During an interview with the Maintenance Director on 2/19/26 at 9:20 A.M., he said he had been working at the facility for only a couple of days and was not familiar with the condition of the bedrooms. The Maintenance Director said he did not know if the facility kept a log of needed repairs or repairs in progress but would look for one and provide it to the surveyor if found. As of the conclusion of the survey the Maintenance Director had not provided a repair log to the surveyor. During an observation on 2/19/26 at 5:40 A.M., the surveyor observed the following in the nourishment room on the 2nd floor nursing unit: The floor was stained with dark brown and black build up along the floor and edges of the door frame. The door frame was cracked and chipped with brown dried liquid stains along the sides. There were two soiled pest traps in the corners of the nourishment room, one in each corner with dead bugs inside. There were pieces of trash inside and surrounding both pest traps. During an interview on 2/19/26 at 8:17 A.M., the Director of Housekeeping said he creates a room cleaning schedule seven days per week and said housekeeping staff are responsible for cleaning the resident care areas. The Director of Housekeeping said that staff should be cleaning the dining areas, resident rooms and nourishment rooms daily. The Director of Housekeeping said he checks the nursing units and resident rooms daily and if they are not clean, he will clean them himself. The Director of Housekeeping said the housekeeping staff sweep and mop the floors seven days a week. The Director of Housekeeping said the cleaners checked off that the nourishment rooms were cleaned on their check-off list and he did not check any of the nourishment rooms yesterday. The Director of Housekeeping said he would expect the cleaners to go into the nourishment rooms and sweep, mop the floors and wipe down surfaces. During an interview on 2/19/26 at 9:01 A.M., Consultant #1 said it is her expectation that staff report environmental issues daily and that resident rooms and care areas are cleaned thoroughly and appropriately.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure two of two nourishment kitchens were maintained in a clean, sanitary condition and failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.Findings include:Review of the facility policy titled Nutrition Services, undated, indicated but was not limited to the following: 4. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 Fahrenheit (F) to 135 F) will be kept to a minimum. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. Review of the facility policy titled Food Safety, dated August 2011 indicated but was not limited to the following:It is the policy of this facility that to follow the food protection guidelines as defined in the Hazard Analysis Critical Control Point (HACCP) system to reduce the risk of food contamination and foodborne illness.b. Food Storage: Minimize exposure of potentially hazardous foods to room temperature. Refrigerator units must be maintained at ,41 [NAME] (F) and freezers ,0 F or a temperature to keep food frozen solid. On 2/19/26 at approximately 5:20 A.M., the surveyor made the following observations in the first-floor nursing unit:-One Resident was observed reaching into a gray cooler while holding a plastic cup and removed the half-filled cup with clear water. The Resident began to sip water from the cup. The surveyor opened the cooler and saw about two inches of water at the bottom of the gray cooler. -One clear pitcher containing apple juice, approximately one quarter full was observed on a metal cart underneath two coolers behind the nurse's station. The pitcher was labeled Date 2/18/26. Use By 2/20/26. The pitcher containing the apple juice and was not on ice and was placed directly on the metal cart. The internal temperature of the apple juice at the time of the observation was measured at 76 degrees F.During an interview on 2/19/26 at 5:25 A./M., Certified Nursing Assistant (CNA) #3 said if residents are thirsty, we use the coolers for ice and water and said apple juice is stored on the metal cart and is used for residents. During an interview on 2/19/26 at 5:30 A.M., Nurse #5 said the gray cooler was filled with ice and the clear pitcher of apple juice was delivered around 7:00 P.M., on 2/18/26 and had been used for residents during the overnight shift. Nurse #5 said the dietary department delivers the cooler of ice and apple juice and said they do not store the juice on ice. Nurse #5 said residents should not be accessing the coolers and drinking from the gray cooler that had melted ice in it and said residents need to ask the nurse for water. During an interview on 2/19/26 at 5:35 A.M., Dietary Staff #3 said the coolers are filled with ice and water and pitchers with apple juice are delivered to the unit on the cart for the staff to use. On 2/19/26 at approximately 6:12 A.M., the surveyor observed the following in the nourishment room on the first-floor nursing unit: -The kitchenette floor was stained throughout the room and had dark brown and black build up along the edges and along the bottom of the cabinets with dried pieces of food and crumbs scattered across the floor. The floor in front of the refrigerator had numerous food stains and dried spilled substances along the side and directly in front of the refrigerator and was sticky. The door frame had a brown dried liquid stain along the top. There were crumbs along the edge of the room along with dead bugs and dust.-The inside cabinet above the sink had pink and brown stains on the bottom shelf, multiple dried food crumbs and one old brown and black banana. There were crumbs along the edge of the cabinet shelves along with dead bugs and dust.-The microwave was placed on top of a broken piece of plaster that had brown, yellow, red, and, rust colored stains across the bottom. The microwave had cracked, chipped and peeling edges along the inside and dark brown buildup located inside with dried food and spilled yellow substance along the inside and buildup of crumbs and debris. There were crumbs under the microwave along with dead bugs and a sticky substance along the handle.-Multiple opened packages crackers and condiment packets were observed between refrigerator and wall and located behind the microwave.On 2/19/26 at approximately 6:15 A.M., the surveyor observed the following in the nourishment room on the first-floor nursing unit:-The inside of the refrigerator felt warm to touch and there was condensation observed along the back and sides. Food containers were wet and there was no thermometer located inside of the refrigerator. Review of the Facility Refrigerator/Freezer Temperature Log dated February 2026, posted on the front of the refrigerator was missing 12 temperatures and was left blank. Further review of the temperature log indicated temperatures above 38 degrees F was recorded on five out of 19 days with the last documented temperature on 2/18/26 in the morning and was 40 degrees F. -The surveyor observed cartons of milk and dietary supplements inside of the refrigerator that felt warm to the touch and had condensation on the outside. The internal temperature of the milk at the time of the observation was measured at 50 degrees F.On 2/19/26 at approximately 5:40 A.M., the surveyor observed the following in the nourishment room on the second-floor nursing unit:-The floor was stained with dark brown and black build up along the floor and edges of the door frame. The door frame was cracked and chipped with brown dried liquid stains along the sides. There were two soiled pest traps in the corners of the nourishment room, one in each corner with dead bugs inside. There were pieces of trash inside and surrounding both pest traps.During an interview on 2/19/26 at 9:14 A.M., Dietary Staff #1 who is the temporary covering Food Service Director, said cold beverage brought to the nursing units must be labeled, dated and on ice. Dietary Staff #1 said apple juice should not be left out for hours at room temperature and should be under 41 degrees. Dietary Staff #1 said refrigerator temperatures must be checked twice daily and reported if temperatures fall out of safe storage range. During an interview on 2/19/26 at 9:17 A.M., Dietary Staff #2 said dietary staff are responsible for checking the nourishment room refrigerator temperatures and said he was unaware of the temperatures not being checked and said staff should report temperatures that are above 38 degrees. Dietary Staff #2 said he would expect the dietary staff to clean out the refrigerator and microwave daily and report any issues to housekeeping if further cleaning is necessary. During an interview on 2/19/26 at 7:51 A.M., the Director of Maintenance said he was not aware of the refrigerator temperatures not working and said he does not have an open work order to replace the thermometer in the refrigerator.During an interview on 2/19/26 at 8:17 A.M., the Director of Housekeeping said housekeeping staff should be cleaning the nourishment rooms daily. During an interview on 2/19/26 at 9:05 A.M., Consultant #1 said it is her expectation that staff are checking the nourishment rooms daily and are storing food appropriately. Consultant #1 said she would expect the refrigerators to be in good working order and temperatures to be monitored and reported if out of safe range.

Based on observation and interviews, the facility failed to ensure concerns reported during the Resident Council related to call light responses were thoroughly documented and acted upon timely.Findings include:Review of the facility policy tilted Grievances/Concerns, revised 12/6/21, indicated the following: -Purpose: To provide residents/resident representatives a means of voicing their grievances/concerns freely without fear of retaliation and for facility administration to follow an established process for investigating grievances and complaints in an efficient, comprehensive, and timely manner. -Policy: Residents or their representatives may file a grievance or complaint concerning treatment, medical care, behaviors of other residents, staff members, theft of property, lost clothing, etc. Employees of the facility will assist residents and or their representatives in the grievance/complaint process when such requests are made. -Grievances/concerns may be submitted orally or in writing. The person/staff receiving an oral grievance/concern will fill out the Grievance/concern form for submission to leadership. -Grievances/Concerns will be recorded on the Grievance Log. The Social Services Department/designee will be responsible for recording and maintaining this log. Grievance/concern forms will be kept for a minimum of three (3) years. -Resident Grievances/Concerns and the Grievance Log will be reviewed for trends by the Quality Assurance and Assessment Committee at least quarterly. During an interview and observation on 2/17/26 at 8:27 A.M., Resident #75 said that staff have attitudes and that it is hard to get staff to take care of him/her. Resident #75 also said that his/her call bell did not work. The surveyor pushed Resident #75's call bell to check if it was functioning and heard the call bell sound outside of the Residents room and observed a light, light up at the top of the Residents door. The sound of the call bell immediately stopped sounding, and staff had not entered the Residents room to turn off the call light or check on the Resident. The surveyor had a second observation of the call bell sounding outside of the Residents room once the bell was pressed again and immediately sounding off, with no staff entering the Residents room to check on the Resident and turn off the call light. Review of the Resident Council meeting notes dated November 2025, December 2025 and January 2026 did not indicate concerns related to call lights. Review of the Grievance binder failed to indicate recent concerns/issues regarding call lights or long waiting times. On 2/18/26 at 1:30 P.M., the surveyor held a group meeting with ten residents in attendance. The residents shared the following information:-Nine of ten residents said they do not believe their concerns are thoroughly addressed when issues are brought forward and they are not provided a rationale for the response.-Nine of ten residents said they do not feel comfortable to complain about care without worrying that someone will get back at them. - Nine of ten residents said they do not get the help and care they need without waiting a long time and they are waiting 45 minutes to hours for staff to respond to their call lights. -Nine of ten residents said they are afraid to call for help because when staff finally respond to their call bells, they are rude and start yelling at them questioning why the call bell was pushed.-Nine of ten residents said they have complained about long call light wait times at resident council and feel like nothing is being done to address the issue. -Four out of ten residents said they stopped using their call light in fear of the response from the staff. During an interview and observation on 2/19/26 at 8:07 A.M., Nurse #3 said that staff can mute the sound of the call bell from the nurse's desk but that the actual call light must be cancelled from the resident's room. Nurse #3 went into a Residents room and pushed the call bell to demonstrate the call light system. The light lit up on top of the resident's door and the call bell sounded as the light was lit up. Nurse #3 came back to the nurse's desk and clicked a button on the call light system screen and the sound to the call bell had immediately muted but the light outside the Residents room remained lit up. The Maintenance Director was present during this observation. During an interview on 2/19/26 at 9:26 A.M., the Activities Director said that call bells have been a complaint a long time ago and that residents continue to complain of long call light waiting times at resident council. The Activities Director said that there was an in-service that was conducted by the Administrator with the staff regarding the call lights and that the issue was resolved. She furthermore said that the continued complaints about the long call light waiting times did not arise to a grievance being documented from her perspective because the in-service is an ongoing process and the issue was resolved by the Administrator. She also said that the concerns would be brought to morning meeting. During an interview on 2/19/26 at 9:45 A.M., the Administrator said that he would expect to be told about ongoing complaints coming from resident group and that he was not made aware of concerns with long call light waiting times. The Administrator said call lights have not been something that was brought up in the morning meeting and that the complaints should be in the resident council minutes.

Based on observation, record review and interview, the facility failed to alert the physician and the behavioral health provider of an increase in sexually inappropriate behaviors for one Resident (#8) out of a total of 18 sampled Residents. Findings include: Review of the facility's Change in Resident's Condition or Status and Notification policy, dated 1/1/20 indicated: The RN (Registered Nurse) Supervisor/Charge Nurse will notify the resident's Attending Physician, Physician extender or on-call physician when there has been a significant change in the residents medical/mental conditions and/or status but not limited to: d.) a change/deterioration in the residents physical/emotional/mental condition.Resident #8 was admitted to the facility in July 2024 with diagnoses including schizophrenia, toxic encephalopathy and epilepsy. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #8 is severely cognitively impaired evidenced by a score of 6 out of a possible 15 on the Brief Interview for Mental Status Exam. On 2/17/26 at approximately 10:00 A.M., the surveyor observed Resident #8 agitated and swearing in the hallways of the unit. Review of the nurse progress notes indicated: 1/20/26: Cursing/screaming/yelling at people sometimes with 1:1 redirection and fair effect. 1/21/26: Cursing/screaming/yelling at people at times with little effect when redirected. 1/23/26: Sometimes cursing/screaming/yelling and touching people inappropriately with effect when redirected. 1/26/26: Cursing/screaming/yelling/coming out of his/her room with no pants on or topless/touching people inappropriately with little effect when redirected. 1/29/26: Cursing/screaming/yelling at people at times with little effect when redirected. 2/2/26: Cursing/screaming/yelling at people at times with little effect when redirected. 2/3/26: At times cursing/screaming/yelling/coming out of his room with no pants on or topless/ touching people inappropriately with little effect when redirected. 2/4/26: Still cursing/screaming/yelling/coming out of his room with no pants on or topless/touching people inappropriately with little effect when redirected. 2/6/26: Sometimes cursing/screaming/yelling/coming out of his/her room with no pants on or topless/ touching people inappropriately with little effect when redirected. 2/8/26: Resident being sexually inappropriate and attempting to go over this writer's feet with w/c (wheelchair). Resident was redirected and attempted again. 2/9/26: At times cursing/screaming/yelling/coming out of his/her room with no pants on or topless/ touching people inappropriately with little effect when redirected. 2/12/26: Sometimes cursing/screaming/yelling/coming out of his/her room with no pants on or topless/ touching people inappropriately with little effect when redirected. 2/17/26: At times cursing/screaming/yelling/coming out of his/her room with no pants on or topless/ touching people inappropriately with little effect when redirected.The clinical record failed to indicate the physician or behavioral health services were notified of Resident #8's behaviors of touching staff inappropriately.Review of the physicians notes and behavioral health notes failed to include information related to Resident #8's sexual behaviors. During an interview on 2/17/26 12:52 P.M., Nurse #1 said that Resident #8 has behaviors including grabbing female staff's privates/breasts and buttocks. Nurse #1 said that Resident #8 had behaviors of being inappropriate but recently the behaviors have gotten worse. Nurse #1 said that Resident #8 does not attempt to touch other residents, just staff.Review of Resident #8's care plans indicated: Focus: I can and have been socially inappropriate and disruptive to others r/t (related to) intrusive at nurses station, socially inappropriate, initiated 7/29/24.Goal: I will demonstrate only socially appropriate behaviors. I will not disrupt fellow residents or staff by my behaviors through the next review date. 7/29/24. The Resident demonstrates sexually inappropriate behavior toward staff; revised 2/11/26Interventions: Please allow distance when seating me around others to avoid adverse behaviors. Please always approach me in a calm welcoming manner, please assess if my behavior endangers myself or others and intervene as needed. Please avoid an overstimulated area. Loud noises, crowds and other verbally aggressive residents may trigger behaviors. Remove me to a quiet place with a calming activity. Please document my behaviors on the behavior monitoring sheet. Please establish limits for inappropriate behaviors. Please explain the consequences of my behavior in a way I will understand. Please monitor me when I am up and keep me where you can observe me for inappropriate behaviors. Re-direct me as needed. Please provide 1:1 sessions with the social worker as needed. Please provide me with psych services as needed. (7/29/24)Although the care plan was updated on 2/11/26 to include Resident #8 had sexually inappropriate behaviors, the care plan failed to indicate specific behaviors Resident #8 was demonstrating and failed to update new interventions to address his/her behaviors. Review of the physician orders included monitoring Resident #8's behaviors of intrusiveness, refusal of care, yelling and swearing, but did not include monitoring for sexually inappropriate behaviors. During an interview on 2/18/26 at 7:42 A.M., Nurse #2 said she is an agency nurse but is aware that Resident #8 has behaviors of grabbing at female staff during care. Nurse #2 said she did not think that Resident #8 attempts to touch other residents. On 2/18/26 at 8:39 A.M., the surveyor was standing in the hallway of the 1st floor unit and observed Resident #8 being wheeled down the hallway by a Certified Nursing Assistant (CNA). Resident #8 reached his/her hand and attempted to touch the surveyor's breast. The surveyor put her hand out to deter the Resident from touching her chest. On 2/18/26 at 8:48 A.M., the surveyor observed Nurse #1 assist Resident #8 with his/her breakfast meal. Resident #8 attempted to touch Nurse #1's genitals and Nurse #1 had to move his/her hand. Resident #8 continuously called Nurse #1 his/her girlfriend and also attempted to kiss Nurse #1. Nurse #1 continuously verbally redirected Resident #8 but his/her behaviors continued. On 2/18/26 at 8:54 A.M., Resident #8 was observed self-propelling in his/her wheelchair out of the dining area. Resident #8 reached his/her hand toward Nurse #2's breasts and Nurse #2 stepped out of the way. Resident #8 said Hey, you're cute you wanna go on a date? During an interview on 2/18/26 at 8:56 A.M., CNA #1 said that Resident #8 grabs female staff during care and she's heard staff yell for help while in his/her room because he/she is trying to touch them. CNA #1 said she did not think Resident #8 attempts to touch residents. During an interview on 2/18/2026 at 9:05 A.M., Nurse #1 confirmed the surveyor's observations and said that Resident #8 tried to touch her genitals and tried to kiss her during the breakfast meal. During an interview on 2/18/26 at 7:59 A.M., the Director of Nursing (DON) said that the facility emails behavioral health services with updates regarding resident needs or increased behaviors.Review of the emails between facility and behavioral health services provided to surveyor dated 1/11/26, 1/12/26, 1/14/26 and 2/14/26 failed to include information related to Resident #8's increased behaviors. During an interview on 2/18/26 at 12:02 P.M., the Psychiatric Nurse Practitioner said that she is alerted via email by the facility for any changes in resident behaviors or requests to see residents. The Psychiatric NP said that although she was aware of Resident #8's history of being vocally sexually inappropriate she was not aware of any behaviors of him/her touching female staff. The Psychiatric NP said she would expect to be notified of these kinds of behaviors to review with staff and discuss possible interventions. During an interview on 2/18/26 at 12:56 P.M., the DON said that the provider and behavioral health services should be alerted when a resident is experiencing increasing behaviors. The DON said the social worker is responsible for emailing behavioral health services with updates with resident status and requests for residents to be seen. The DON said she had been told that Resident #8 had been sexually inappropriate and touching staff and would expect staff to monitor those behaviors and to implement interventions to address the behaviors. The DON said she was not aware that the Psychiatric NP was not notified of an increase in Resident #8's behaviors or there was no behavior monitoring for Resident #8's sexually inappropriate behaviors. During an interview on 2/19/26 at 7:49 A.M., the Social Worker said that Resident #8 has varying behaviors and can be sexually inappropriate. The Social Worker said she was told a long time ago that Resident #8 had grabbed a staff person inappropriately but was not aware that the behaviors were re-occurring or escalating. The Social Worker said it is not solely her responsibility to email updates to behavioral health services, but she will do so as things are reported in meetings. The Social Worker said she did email recently for Resident #8 to be seen by behavioral health services but did not include the information related to his/her increased sexual behaviors because she was not aware.During an interview on 2/19/26 at 10:37 A.M., Physician #1 said that when residents are experiencing an increase in behaviors, staff are expected to notify him and behavioral health services. Physician #1 said he was familiar with Resident #8 and was not aware that he/she was having sexual behaviors or touching female staff inappropriately.

Based on record review and interview the facility failed to report an allegation of verbal abuse to the State Agency for one Resident (#24) out of 18 sampled residents. Specifically, an allegation of verbal abuse was submitted to the facility on 2/11/26 but not reported to the State Agency until 2/18/26.Findings include:Review of the facility's Abuse Prohibition policy last revised on 2/20/23, indicated:Report the incident immediately to the Director of Nursing and/or Administrator.The Administrator is responsible for ensuring that there has been notification [of] local law enforcement and the State Survey Agency within 2 hours of allegation after identification of alleged/suspected incident.Review of the facility's Grievance Log indicated that on 2/11/26 Family Member #1 reported that a staff member cursed at Resident #24 after he/she asked for help to clean the floor. The Grievance Log Action Taken entry indicated Supervisor cleaned wet floor and educated staff on what needs to happen when resident needs support. The Action Taken entry did not reference a response to the staff cursing at the Resident.Review of the Grievance/Concern Report Form dated 2/11/26 and signed by the Director of Social Services indicated Family Member #1 was talking on speaker phone with Resident #24 that day. The report indicated Family Member #1 said she overheard the Resident ask a housekeeper to clean an area in his/her bedroom. Family Member #1 said she heard the housekeeper then curse.During an interview 2/17/26 at 2:19 P.M., Family Member #1 said that on 2/11/26 during the afternoon she was on speaker phone with Resident #24. Family Member #1 said that a staff member was present during the call. Family Member #1 said he/she heard Resident #24 ask the staff person to clean his/her area, Family Member #1 said she then heard the staff person repeatedly say, Fuck this. Family Member #1 said she told the Director of Social Services that day about the incident. Review of the Health Care Facility Reporting System (HCFRS; an internet gateway to report allegations of abuse and other reportable incidents to the State Agency) on 2/20/26 at 12:03 P.M. indicated the facility did not report the allegation until 2/18/26. The HCFRS report indicated that on 2/11/26 a staff member allegedly verbally abused Resident #24. The facility did not submit the allegation of verbal abuse to the State Agency within the required two-hour time frame.During an interview on 2/18/26 at 8:56 A.M., Consultant #2 said she and the Administrator first learned this morning about the incident involving Resident #24 and a staff member. Consultant #2 said department heads are responsible for immediately informing the Director of Nursing or the Administrator of allegations of abuse. Consultant #2 said the facility is required to report allegations of abuse within two hours to the State Agency.During an interview on 2/19/26 at 7:49 A.M., the Director of Social Services said Family Member #1 called her on 2/11/26 to report that she had been speaking with Resident #24 that day. Family Member #1 told her that she overheard a housekeeper saying fuck you to the Resident.The Director of Social Services said she entered Family Member #1's complaint into the Grievance Log and on the Grievance /Concern Report form. The Director of Social Services said she told the Director of Housekeeping about the incident. The Director of Social Services told the surveyor she did not know the identity of the housekeeper. The Director of Social Services said the Director of Housekeeping was responsible for investigating the incident and addressing action steps, including informing the Administrator about the incident. The Director of Social Services said she did not know why the Director of Housekeeping did not reference the housekeeper's cursing on the Grievance Log or on the Grievance/Concern Report Form.The Director of Social Services said she then visited Resident #24 to ask how he/she felt about the incident. The Director of Social Services said she was accompanied by another staff person who could translate to English because the Resident spoke primarily Spanish. Through the translator Resident #24 said he/she felt fine and that a housekeeper did not curse at him/her. The Director of Social Serviced said that because Resident #24 denied anyone cursed at him the incident did not need to be reported to the Administrator or Director of Nursing. The Director of Social Services said the Administrator are responsible for monitoring submitted grievances.During an interview on 2/19/26 at 8:04 A.M., the Director of Housekeeping said that on 2/11/26 sometime after 2:30 P.M., the Director of Social Services told him there was a complaint that no one cleaned up puddles in Resident #24's room. The Director of Housekeeping said the Director of Social Services told him she had looked for a housekeeper to mop but she could not find one in the building. The Director of Housekeeping said all the housekeepers had left for the day, so he cleaned the puddles himself. The Director of Housekeeping said no one told him there was an incident or that a housekeeper cursed at the Resident. The Director of Housekeeping said, according to the schedule, Housekeeper #1 was assigned to clean Resident #24's room on 2/11/26 at the time of the incident.The Director of Housekeeping said that if someone told him there was an allegation of abuse, he would have immediately informed either the Administrator or Director of Nursing.During an interview with the Administrator, Consultant #1 and Consultant #2 on 2/19/26 at 9:30 A.M., they said they had been unaware of Family Member #1's allegation until today. They said the allegation did not need to be reported to the State Agency because Resident #24 denied the incident occurred.

Based on record review and interview the facility failed to investigate an allegation of verbal abuse for one Resident (#24), out of 18 sampled residents. Specifically, a Family Member reported an allegation of verbal abuse to the facility on 2/11/26, but an investigation did not begin until 2/18/26; approximately seven days later. Findings include:Review of the facility's Abuse Prohibition policy last revised on 2/20/23, indicated:The shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process. The Administrator and Director of Nursing are responsible for investigation and reporting.The investigation will begin immediately after reporting the actual or suspected incident.Review of the facility's Grievance Log indicated that on 2/11/26 Family Member #1 reported that a staff member cursed at Resident #24 after he/she asked for help to clean the floor. The Grievance Log Action Taken entry indicated Supervisor cleaned wet floor and educated staff on what needs to happen when resident needs support. The Action Taken entry did not reference a response to the staff cursing at the Resident.Review of the Grievance/Concern Report Form dated 2/11/26 and signed by the Director of Social Services indicated Family Member #1 was talking on speaker phone with Resident #24 that day. The report indicated Family Member #1 said she overheard the Resident ask a housekeeper to clean an area in his/her bedroom. Family Member #1 said she heard the housekeeper then curse.During an interview on 2/17/26 at 2:19 P.M., Family Member #1 said that on 2/11/26 during the afternoon she was on speaker phone with Resident #24. Family Member #1 said that a staff member was present during the call. Family Member #1 said he/she heard Resident #24 ask the staff person to clean his/her area, Family Member #1 said she then heard the staff person repeatedly say, Fuck this. Family Member #1 said she told the Director of Social Services that day about the incident. During an interview on 2/19/26 at 7:49 A.M., the Director of Social Services said Family Member #1 called her on 2/11/26 to report that she had been speaking with Resident #24 that day. Family Member #1 told her that she overheard a housekeeper saying fuck you to the Resident.The Director of Social Services said she entered Family Member #1's complaint into the Grievance Log and on the Grievance /Concern Report form. The Director of Social Services said she told the Director of Housekeeping about the incident. The Director of Social Services said the Director of Housekeeping was responsible for investigating the incident and addressing action steps, including informing the Administrator about the incident. The Director of Social Services said the Administrator are responsible for monitoring submitted grievances.During an interview on 2/19/26 at 8:04 A.M., the Director of Housekeeping said that on 2/11/26 sometime after 2:30 P.M., the Director of Social Services told him there was a complaint that no one cleaned up puddles in Resident #24's room. The Director of Housekeeping said no one told him there was an incident or that a housekeeper cursed at the Resident. The Director of Housekeeping said he did not investigate the incident.During an interview with the Administrator, Consultant #1 and Consultant #2 on 2/19/26 at 9:30 A.M., they said they were made aware of Family Member #1's allegation today and would begin an investigation.

Based on observation and interview, the facility failed to secure medications for one of two medication storage areas. Specifically, the second floor medication cabinet was unlocked and medications were accessible to staff, residents and visitors.Findings include:Review of the facility's policy Storage of Medications (undated) indicated:Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed personnel, pharmacy personnel or staff members lawfully authorized to administer medications.Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access.On 2/18/26 at 7:48 A.M. the surveyor observed the second floor medication cabinet unlocked, located at the nursing station. An open padlock hung from its clasp and there were no other means to lock the cabinet. The surveyor observed a refrigerator inside the cabinet, and it was unlocked. The surveyor opened the refrigerator door and observed:5 vials of various insulin types3 insulin pens1 bottle of probiotics3 squeeze bottles of ophthalmic solutions 1 respiratory inhalerNo narcotics were in the refrigerator.During the observation there were no licensed staff at the nursing station or in sight of the medication cabinet. A nurse administering medications was located around the corner in the hallway, but not in sight of the medication cabinet and was unaware the surveyor had opened the cabinet.Between 7:48 A.M. and 10:20 A.M. the surveyor observed that the medication cabinet remained unlocked and the padlock hung from its hasp. During this time licensed and non-licensed staff entered and exited the nursing station but did not lock the cabinet.During an interview on 2/18/26 at 10:20 A.M., the surveyor showed Consultant #1 the unlocked medication cabinet. Consultant #1 proceeded to lock the cabinet. Consultant #1 said the medication cabinet should never be unlocked unless a nurse was present.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document a urinary catheter change.Findings include:The Facility Policy, titled, Charting and Documentation, undated, indicated observations, medications administered, services performed, etc., would be documented in the residents' clinical records.Resident #1 was admitted to the Facility in May 2023, diagnoses included Cauda Equina Syndrome (injury or herniated disk compresses nerve roots at the bottom of your spinal cord. The cauda equina nerves communicate with your legs and bladder. It causes back pain, weakness and incontinence) and neuromuscular dysfunction of the bladder.Review of Resident #1's August and September 2025 active Physician's Orders, indicated he/she had a physician's order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage.Further review of Resident #1's August and September 2025 active Physician's Orders indicated he/she had a second Physician's Order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage or dislodgement every eight hours as needed.Review of Resident #1's Hospital History and Physical (H&P), dated 09/13/25, indicated he/she was transferred from the Facility to the Hospital Emergency Department with symptoms of a urinary tract infection. The Hospital H&P indicated his/her indwelling urinary catheter was last changed at the Facility two and a half to three months earlier.Review of the Facility's internal investigation, dated 09/25/25, indicated the Facility discovered through their investigation process that Nurse #1 had changed Resident #1's indwelling urinary catheter on 08/16/25, but had not documented the catheter change anywhere.Review of Resident #1's Treatment Administration Record (TAR) for August 2025 indicated nursing did not check off that his/her indwelling urinary catheter was changed on any days that month.Review of Resident #1's medical record indicated there was no documentation to support that nursing changed his/her indwelling urinary catheter on 08/16/25.During a telephone interview on 10/15/25 at 02:26 P.M., Nurse #1 said that on 08/16/25 she had changed Resident #1's Foley catheter at his/her request due to discomfort and blockage. Nurse #1 said she did not document the procedure anywhere in Resident #1's medical record but should have.During an interview on 10/15/25 at 09:45 A.M., the Director of Nurses (DON) said Nurse #1 should have documented Resident #1's indwelling urinary catheter change on 08/16/25, and said nursing should document care related to indwelling urinary catheters daily but had not.

Based on observations, record review and interview, the facility failed to meet professional standards of practice for five Residents (#46, #43, #20, #42 and #11) out of a total sample of 23 residents. Specifically: 1. For Resident #46, the facility failed to follow a physician's recommendation to send the resident to an outside clinic. 2. For Resident #43, the facility failed to obtain a physician's orders for air mattress settings 3. For Resident #20, the facility failed to obtain a physician's orders to hold a tube feeding when the Resident was away from the facility. 4. For Resident #42, the facility failed to follow physician's orders regarding air mattress settings. 5. For Resident #11, the facility failed to implement physician's orders for heel booties and elevating heels off the mattress. Findings include: 1. Resident #46 was admitted in October 2024 with diagnoses including methicillin resistant staphylococcus aureus (MRSA) and human immunodeficiency virus (HIV) disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #46 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's note, dated 11/19/24, indicated the following: -Patient needs to follow-up with HIV clinic as per the staff patient question about this diagnosis so if the patient follows up with the HIV clinic will be able to know whether this is an accurate diagnosis and whether the patient needs treatment related there is no signs of opportunistic infections [sic] Review of the medical record failed to indicate if Resident #46 was ever seen by the HIV clinic to determine his/her HIV status. During an interview on 12/12/25 at 12:14 P.M., Physician #1 said that he remembers making that recommendation and believes the facility was trying to get an appointment for an infectious disease clinic, but they can be hard to get. The facility failed to provide any documentation supporting that Resident #46 had an appointment with an HIV clinic. 2. Resident #43 was admitted in April 2024 with diagnoses including hypertension, hemiplegia, and cerebral infarction. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #43 scored an 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During an observation on 2/11/25 at 9:20 A.M., Resident #43 was lying in bed on an air mattress set to 150 pounds of pressure. During an observation on 2/12/25 at 8:33 A.M., Resident #43 was lying in bed on an air mattress set to 150 pounds of pressure. Review of the medical record failed to indicate any physician order for the air mattress or supporting care plan for the appropriate air mattress settings. During an interview on 12/12/25 at 11:02 A.M., the Director of Nursing said that she would expect an order or a care plan for the use of an air mattress with the appropriate settings. 46339 3. Resident #20 was admitted to the facility in March 2024 with diagnoses including multiple sclerosis, dysphagia and dependence on tube feeding. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. During an interview on 2/12/25 at 6:45 A.M., Resident #20 was observed lying in his/her bed, the Resident told the surveyor he/she had gone on a leave of absence to his/her apartment the day before at around 12:00 P.M., and returned to the facility around 7:00 P.M. The Resident said he/she does not eat anything by mouth and so he/she goes without food when he/she is away from the facility. Review of the current physician orders indicated the following: -NPO diet (Nothing by Mouth) texture, thin liquids consistency. -Enteral feed order every shift infuse Osmolite 1.5 at 55 ml (milliliter)/ hour x 24 hours. Review of the medical record failed to indicate a physician's order had been obtained for holding the tube feeding when the Resident was away on a leave of absence. During an interview on 2/12/25 at 11:15 A.M., Nurse #1 said the Resident receives the tube feeding continuously. She further said there should be an order to hold the tube feed if the Resident is out of the facility. During an interview on 2/12/25 at 11:33 A.M., Unit Manager #1 said there should be an order to hold the tube feeding when the Resident is out of the facility. 49880 4. Resident #42 was admitted to the facility in May 2023 with diagnoses that include neuromuscular dysfunction of the bladder. Review of Resident #42's most recent Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated a Brief Interview for Mental Status score of 15 out of 15 indicating that the Resident is cognitively intact. The MDS indicated that Resident #42 does not have pressure injuries but is at risk for development of pressure injuries. Review of Resident #42's physician's orders indicated the following order, dated 9/25/23: -Air Mattress to bed at all times set to 325 Alternating. Check placement and functioning every shift. Review of Resident #42's most recent Norton Assessment (an assessment to determine the risk for skin breakdown), dated 1/20/25 indicated a score of 8 indicating that Resident #42 is at high risk for developing pressure ulcers. Review of Resident #42's active activities of daily living care plan indicated an intervention for air mattress for pressure prevention to be set as ordered, dated as initiated 4/10/24. On 2/11/25 at 8:00 A.M., Resident #42 was observed sleeping in bed. An air mattress was in place and set to 150. On 2/12/25 at 7:17 A.M. and 8:39 A.M., Resident #42 was observed lying in bed. An air mattress was in place and set to 150. During an interview on 2/12/25 at 11:02 A.M., the Director of Nursing said that nurses should be checking air mattress orders and settings every shift to ensure that they are at the correct settings. 5. Resident #11 was admitted to the facility in July 2024 with diagnoses including chronic pain syndrome and lack of coordination. Review of Resident #11's most recent Minimum Data Set (MDS) Assessment, dated 1/9/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident is at risk of developing pressure ulcers. Further the MDS indicated rejection of care 1-3 days during the lookback period. Review of Resident #11's most recent Norton Assessment (an assessment utilized to determine a resident's risk for skin breakdown), dated 1/6/25, indicated a score of 12, indicating that the Resident is at high risk for skin breakdown. Review of Resident #11's active risk for skin breakdown care plan, dated 7/23/24, indicated an intervention to Please elevate my heels off the mattress while in bed. Review of Resident #11's active physician orders indicated the following: -Apply foam booties to bilateral heels when in bed may remove for care, dated 7/11/24. -offload heels whenever in bed, dated 7/11/24. -On 2/11/25 at 8:08 A.M., Resident #11 was observed lying in bed on his/her back. His/her heels were directly on the mattress. Resident #11 said that their left heel often hurts. Heel booties were observed stuffed between the bureau and the wall. -On 2/12/25 at 7:16 A.M. and 8:38 A.M., Resident #11 was observed lying in bed on his/her back. His/her heels were directly on the mattress. Heel booties were observed stuffed between the bureau and the wall in the same place as previously observed. -On 2/13/25 at 6:53 A.M., Resident #11 was observed lying in bed on his/her back. His/her heels were directly on the mattress. Heel booties were observed stuffed between the bureau and the wall in the same place as previously observed. Review of the February 2025 Treatment Administration Record failed to indicate refusal of booties to heels or elevation of heels off the mattress, and during the survey were signed off indicating treatment occurred, and failed to indicate rejection of care. During an interview on 2/13/25 at 9:47 A.M., the Corporate Nurse said that physician's orders should be implemented as written and documented accurately in the medical record.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the main kitchen refrigerators, and that dented cans were not accepted into storage/circulation. Findings include: Review of the facility's undated policy titled Food Receiving and Storage, indicated, but was not limited to, the following: - When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. - All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 2/11/25 at 6:51 A.M., the surveyor observed a significantly dented can of carrots, a significantly dented can of beef stew, and three significantly dented cans of tropical fruit salad on the can rack in the kitchen storage room. On 2/11/25 at 6:51 A.M., the surveyor made the following observations in the main kitchen refrigerator: -One opened, undated and unlabeled ham roast. -One pan of cooked meat in juices, undated and unlabeled. During an interview on 2/11/25 at 7:36 A.M., the cook said that dented cans should not go on the can rack and should instead be placed in the office. During an interview on 2/11/25 at 7:13 A.M., the cook said that all food in the kitchen refrigerators should be dated and labeled. During an interview on 2/12/25 at 8:00 A.M., the Food Service Director (FSD) said dented cans should be set aside in the office to be returned as they pose a risk for botulism if consumed (a rare but serious illness caused by a toxin that attacks the nervous system and can lead to paralysis and death). The FSD said that the meats in the refrigerator should be dated and labeled when opened.

Based on record review and interview the facility failed to maintain accurate and complete medical records for four Residents (#46, #43, #3 and #20) out of a total sample of 23 residents. Specifically, 1. For Resident #46 the facility failed to maintain an accurate diagnosis list. 2. For Resident #43 the facility failed to document the appropriate location of a blood pressure measurement. 3. For Resident #3 the facility failed to ensure that the medical record included information pertaining only to that resident. 4. For Resident #20 the facility failed to accurately document the intake of enteral feeding per day. Findings include: 1. Resident #46 was admitted in October 2024 with diagnoses including methicillin resistant staphylococcus aureus (MRSA) and human immunodeficiency virus (HIV) disease. Review of the minimum data set (MDS), dated [DATE], indicated Resident #46 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During observations throughout survey, Resident #46 did not have any precautions in place for any infectious disease. Review of the hospital discharge paperwork, dated 10/24/24, indicated Resident #46 had a skin wound on his/her upper lip, but was swabbed negative for MRSA. Review of the diagnosis list for Resident #46 indicated he/she has MRSA on the lip. Review of the current physician's orders indicate Resident #46 is receiving Mupirocin ointment (a topical ointment for bacterial skin infections) for a MRSA infection. During an interview on 2/12/24 at 12:14 P.M., Physician #1 said he was never able to figure out if Resident #46 had MRSA or not. Review of the medical record indicated Resident #46 has an active diagnosis of MRSA despite being admitted from the hospital with a negative MRSA diagnosis. 2. Resident #43 was admitted in April 2024 with diagnoses including hypertension, hemiplegia, and cerebral infarction. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #43 scored an 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the care plan for Resident #43 indicated the following: Focus- Blood pressure to be taken on the left leg only due to vascular implants and grafts (initiated 4/25/24) Review of the physician's orders for Resident #43 indicated the following: - TAKE BP [blood pressure] on LEFT LEG only (initiated 4/13/24) Review of the Vitals Summary for blood pressure indicated that Resident #43's blood pressure was taken on the right or left arm 15 times during the month of February. During an interview on 2/12/25 at 11:02 A.M., the Director of Nursing said that nurses should be documenting on the appropriate location that they take the blood pressure and not taking or documenting the blood pressure on either arm. 3. Resident #3 was admitted in October 2010 with diagnoses including anemia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #3 requires assistance to dependence with activities of daily living. Review of the medical record indicated that on 7/1/24 a progress note from another resident from another building was uploaded to the medical record of Resident #3. During an interview on 12/12/25 at 11:02 A.M., the Director of Nursing said that Resident #3's medical record should not contain any other medical information from any other resident. 46339 4. Resident #20 was admitted to the facility in March 2024 with diagnoses including multiple sclerosis, dysphagia, gastrostomy status. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident utilizes a feeding tube. During an interview on 2/12/25 at 6:45 A.M., Resident #20 was observed lying in his/her bed, the Resident told the surveyor he/she had gone on a leave of absence to his/her apartment the day before at 12:00 P.M., and returned to the facility at 7:00 P.M. The Resident said he/she does not eat anything by mouth and so he/she goes without food when he/she is away from the facility. Review of the current physician orders indicated the following: -Enteral feed order every shift infuse Osmolite 1.5 at 55 ml (milliliter)/ hour x 24 hours. -Enteral tube feed intake every shift. -Free water bolus at 160 ml (milliliter) every 4 hours. Review of the medication administration record (MAR) for February 2025 indicated incorrect documentation of the enteral intake amount. On 2/11/25 the MAR indicated incorrect documentation as the Resident had been out of the facility for about seven hours. Further review of the MAR indicated inconsistency with the amount documented per shift and per day. During an interview on 2/12/25 at 11:15 A.M., Nurse #1 said the Resident receives the tube feeding continuously and the total enteral intake should be the osmolite at 55 ml/hour for 8 hours per shift and including the water flushes. She further said there were multiple shifts with inaccurate total intake documentations. During an interview on 2/12/25 at 11:33 A.M., Unit Manager #1 said the nurses should document accurately the enteral intake.

Based on record review and interview the facility failed to create a baseline plan of care within the required 48 hours of admission for one Resident (#373) out of a total sample of 23 residents. Findings include: Resident #373 was admitted to the facility in January 2025 with diagnoses including acute embolism and deep vein thrombosis of the left upper extremity. Review of the medical record failed to indicate a baseline care plan was completed within 48 hours of admission. During an interview on 2/12/25 at 11:44 A.M., Unit Manager #1 said a baseline care plan should be completed within two days of admission, she further said that the care plan is necessary to guide the care givers on the resident's care needs.

Based on observation and interview, the facility failed to provide a dignified existence for one Resident (#3) out of a total sample of 23 residents. Specifically, staff failed to pull the privacy curtain or shut Resident #3's door when he/she was in bed without a top on, which exposed Resident #3 to others passing by in the hallway. Findings include: Review of the facility policy titled Dignity/Quality of Life, dated 12/6/21, indicates the following: - Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with care and treatment procedures. Resident #3 was admitted to the facility in October 2010 with diagnoses including anemia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #3 requires assistance to dependence with activities of daily living. Review of Resident #3's current care plan indicates the following: Focus: At times I like to lie naked in bed (initiated 7/3/17). Intervention: Please assist me with the privacy curtain as needed when I want to not wear briefs or clothes (initiated 12/3/19). During an observation on 2/12/25 at 8:47 P.M., Resident #3 was lying in bed topless with his/her privacy curtain open and the bedroom door open to the hallway. Resident #3 had a breakfast tray by his/her bedside that had been dropped off by a staff member. During an interview on 2/12/25 at 8:51 A.M., Nurse #2 said that Resident #3 is very behavioral and will pull open the curtain with a stick. When asked to show the surveyor what stick Resident #3 uses to access the curtain, Nurse #2 could not find it in Resident #3's room. Nurse #2 said he does understand that it is a dignity issue and said it was hard to close the bedroom door because the other roommate likes the door open, but agreed Resident #3's curtain should be closed if he/she is topless. During an interview on 2/12/25 at 11:08 A.M., the Director of Nursing said that if a Resident is exposed, she would expect the privacy curtain to be pulled closed. During an observation on 2/13/25 at 7:38 A.M., Resident #3 was lying in bed topless with the curtain open and the door open, exposing Resident #3 to the hallway.

Based on observation, record review, and interview, the facility failed to notify the physician of a change in condition related to edema for one Resident (#19) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Change of Condition- Physician Notification, dated 1/10/17, indicated the following: - A change in condition is a significant clinical symptom(s) or development, which requires assessment and intervention - It is then the RN supervisor's responsibility to do a follow-up assessment and to ensure that the assessment is documented. - All assessment findings and relevant information should be compiled prior to calling the physician to ensure accuracy of information. - The physician (or alternate) will be contacted to report findings. Resident #19 was admitted in October 2019 with diagnoses including history of an embolism of the lower extremity and hemiplegia of the left side. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated Resident #19 requires substantial assistance to dependence with activities of daily living. During an observation on 2/11/25 at 8:14 A.M., Resident #19 was lying in bed with his/her left leg exposed. Resident #19's left leg was large and swollen throughout the leg. Resident #19 said that he/she has had increased leg swelling and pain in his/her left calf since last week. Resident #19 said he/she told his/her occupational therapist about it, but no one has done anything about it. Review of the medical record failed to indicate that Resident #19 had any edema or diagnoses that would cause edema of the left leg. During an interview on 2/12/25 at 12:31 P.M., Nurse #2 said that Resident #19's leg has been like that for a while and that it is not pitting edema. Nurse #2 said that he does not think the Nurse Practitioner or Physician had been notified because it is normal for Resident #19. Nurse #2 could not say what was causing the swelling. During an interview on 2/12/25 at 12:46 P.M., Rehab Staff #1 said that she has worked with Resident #19 recently and knows that Resident #19 notified nursing of his/her leg swelling. Rehab Staff #1 said that as far as she knows, the swelling has gotten worse. During an interview on 2/12/25 at 1:27 P.M., Rehab Staff #2 said that she worked with Resident #19 on 2/4/25 and said that Resident #19 told her that his/her leg felt like it had a cramp in it. Rehab staff #2 said she looked at the leg and it was swollen with 2+ edema without redness or warmth. Rehab staff #2 said she notified Nurse #2 and asked Nurse #2 to relay that information to the physician. Rehab staff #2 said she also worked with Resident #19 on 2/11/25 and notified Nurse #2 about the leg swelling again. She said Nurse #2 told her that he's been watching it and it looks the same. Rehab staff #2 was told by Nurse #2 that sometimes Resident #19 can be behavioral. During an interview on 2/12/25 at 1:26 P.M., Nurse Practitioner #1 said she was never notified of the leg swelling, but that Resident #19 has a history of a deep vein thrombosis (occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs. Deep vein thrombosis can cause leg pain or swelling.) During an interview on 2/12/25 at 12:18 P.M., Physician #1 said he was never made aware of the leg edema.

Based on observation and interview, the facility failed to provide a clean and homelike environment for one Resident (#3) out of a total sample of 23 residents. Findings include: Resident #3 was admitted in October 2010 with diagnoses including anemia. Review of the minimum data set (MDS), dated [DATE], indicated Resident #3 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #3 requires assistance to dependence with activities of daily living. During an observation on 2/11/25 at 8:17 A.M., Resident #3 was lying in bed with approximately 6-7 dead cockroaches surrounding his/her bed. During an observation on 2/12/25 at 8:47 A.M., Resident #3 was lying in bed with a soiled brief on the floor next to him/her and approximately 6-7 dead cockroaches surrounding his/her bed. During an observation on 2/13/25 at 7:38 A.M., Resident #3 was lying in bed with a soiled brief on the floor next to him/her and approximately 6-7 dead cockroaches surrounding his/her bed. During an interview on 2/12/25 at 11:04 A.M., the Director of Nursing said that housekeeping should be cleaning rooms daily. During an interview on 2/13/25 at 12:09 A.M., the Corporate Nurse said that she expects the rooms to be cleaned daily and as needed if there are pests in the room.

Based on record review and interviews, the facility failed to investigate a report of drug and alcohol use in the facility, reported by one Resident (#44), out of a total sample of 23 Residents. Findings Include: Review of the facility policy titled, Abuse Prohibition, revised 2/20/23, indicated the following: Policy -Allegations of abuse will be reported and thoroughly investigated. -The Administrator and Director of Nursing are responsible for investigation and reporting. Investigation -The investigation will begin immediately after reporting the actual or suspected incident. -Initiate the investigative process using factual data. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewed and have information regarding the allegation. -The results of the investigation will be documented. -Conclusion must include whether the allegation was substantiated or not and what information supported the decision. -Corrective measures will be implemented and documented post incident. Follow-up Measure -The investigation and the findings will be documented and submitted to the facility's Medical Staff for review. Documentation will be retained by the facility for no less than three (3) years. Resident #44 was admitted to the facility in January 2024 with diagnoses including atrial fibrillation, chronic pain, and anxiety disorder. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 12/20/24, indicated a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15, indicating intact cognition. During an interview on 2/12/25 at 2:41 P.M., Resident #44 said he/she reported to the prior social worker that he/she observed his/her roommate doing drugs in the bathroom and drinking alcohol in the room. Resident #44 said he/she was told to submit a grievance but would not be allowed to write his/her account of his/her observations and if he/she did it would stop there and not go any further. Resident #44 was asked if he/she submitted a grievance, he/she said no because there was no point if the staff were not going to investigate his/her report. During an interview on 2/12/25 at 3:39 P.M., the Corporate Nurse and the Director of Nursing said they were not aware of the report of drug and alcohol use. The Corporate Nurse said she would investigate the matter further and report back. During an interview on 2/12/25 at 4:51 P.M., the Corporate Nurse said the prior social worker said Resident #44 did not want to submit a grievance because it would not go anywhere and that the social worker and the Director of Nursing spoke with the Resident and offered him/her a room change, but Resident #44 declined. The Corporate Nurse said an investigation was not completed and said she would expect all reports on alleged drug and alcohol use in the facility to be investigated. Review of the grievance book on 2/13/25 at 8:35 A.M., indicated a grievance on 1/4/25 submitted by the prior social worker regarding Resident #44 not liking his/her roommate and visitors. The grievance form stated the following: Resident #44 was asked by Social Services and the Director of Nursing to write facts not accusations on the roommate. Resident became upset and said never mind I am going to take care of it myself. Resident was offered a room change then refused and said not to bother. Further review of the grievance book failed to indicate an investigation was completed regarding Resident #44's report of his/her roommates' alcohol and drug use in the facility.

Based on record review and interviews for two Residents (#49 and #67) of 23 sampled residents, the facility failed to ensure staff adequately identified a significant change in the Resident's status and completed a comprehensive Significant Change of Status Assessment Minimum Data Set (MDS) as required. Specifically 1. For Resident #49, the facility failed to identify and complete Significant Change in Status MDS when Resident #49, experienced significant weight loss, had an indwelling urinary catheter removed, and developed a stage 4 pressure wound. 2. For Resident #67, the facility failed to complete a significant change in status MDS when Resident #67 was signed on to hospice care. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated a Significant Change in Status Assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. It defines a significant change as a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. 1. Resident #49 was admitted to the facility in February 2020 with the diagnoses including stroke and quadriplegia. Review of Resident #49's most recent MDS, dated [DATE], indicated the following: -Weight= 165 pounds, weight loss of 5% or more in the last month or 10% or more in the last six months and not on a physician prescribed weight-loss regime. -Always incontinent of urine, with no use of an indwelling urinary catheter. -One stage four pressure ulcer. Review of Resident #49's previous MDS, dated [DATE], indicated: -Weight= 172 pounds, no weight loss. -Indwelling urinary catheter. -No pressure ulcers. Review of Resident #49's nurses progress notes, dated 11/7/24, indicated the indwelling urinary catheter was discontinued. Review of Resident #49's medical record as of the most recent MDS assessment reference date (ARD) of 12/5/24, indicated that the indwelling urinary catheter was never re-inserted after being removed on 11/7/24 (28 days), thus the change from having an indwelling urinary catheter to being incontinent of urine would not be considered self-limiting. Review of Resident #49's wound physician notes, dated 11/7/24, indicated a new stage 4 pressure wound to the coccyx, full thickness. Review of Resident #49's nurse progress notes, dated 11/8/24, indicated treatment done as ordered to coccyx stage 4. Review of Resident #49's medical record as of the most recent MDS ARD of 12/5/24, indicated that Resident #49 continues to have a stage 4 pressure would to the coccyx, thus the change from having no pressure ulcers to having a stage 4 pressure ulcer to his/her coccyx on 10/21/24 (45 days) would not be considered self-limiting. Review of Resident #49's nurse progress note addressing weights and vitals summary, dated 11/11/24, indicated weight warning: value:161.0 (pounds); 7.5% change in three months (12.5%, 23.0); 10.0% change in six months (12.0%, 22.0). Review of Resident #49's weights and vital summary, dated 2/13/24, indicated his/her weights were the following: -9/10/24- 171.5 pounds (Lbs.): 5% weight change compared to weight on 8/13/24 of 184.0 Lbs. (-6.8%; -12.5 Lbs.). -9/17/24- 167 Lbs.: 5% weight change compared to weight on 8/13/24 of 184.9 Lbs. (-9.2%; 17.0 Lbs.) and 7.5% weight change compared to last weight on 6/25/24 of 183.0 Lbs. (-8.7%; 16 Lbs.). -10/1/24- 163.8 Lbs.: 10% weight change compared to weight on 6/25/24 of 183.0 Lbs. (-10.5%; -19.2 Lbs.) and 7.5 % weight change compared to last weight of 7/22/24 of 179.6 Lbs. (-8.8%; 15.8 Lbs.). -10/21/24- 157.2 Lbs.: 10% weight change compared to weight on 4/30/24 of 175.3 Lbs. (-10.3%; -18.1 Lbs.). -10/29/24- 161 Lbs.: 10% weight change compared to weight on 6/25/24 of 183.0 Lbs. (-12%; -22 Lbs.). -11/12/24- 165.2 Lbs.: 10% weight change compared to weight on 7/23/24 of 185.2 Lbs. (-10.8%; 20 Lbs.). -11/26/24- 161 Lbs.: 10% weight changed compared to weight on 6/25/24 of 183.0 Lbs. (-12%; 22 Lbs.). Review of Resident #49's medical record as of the most recent MDS ARD of 12/5/24, indicated that Resident #49 continued to have significant weight loss throughout the quarter (75 days), thus the weight loss would not be considered self-limiting. Although Resident #49 had a documented change in status which indicated he/she had a decline in more than two areas, including a significant weight loss, discontinuation of an indwelling urinary catheter with new urinary incontinence and the development of a new pressure wound, a Significant Change in Status MDS Assessment was not initiated or completed within 14 days as required. During an interview on 2/13/25 at 9:58 A.M., the Director of Nursing (DON) said the MDS nurse monitors residents for the need to complete any Significant Change in Status MDS's. The facility MDS Nurse was not available to interview on 2/13/25. During an interview on 2/13/25 at 11:38 A.M., the MDS trainee, after speaking with the corporate MDS nurse, said Resident #49 was still in acute stages of his/her medical condition and continued to be assessed for changes from his/her baseline, therefore, did not require a significant change of status assessment to be completed according to the RAI (Resident Assessment Instrument) manual guidelines. 46339 2. Resident #67 was admitted to the facility in October 2024 with diagnoses including malignant neoplasm of temporal lobe, depression and dementia. Review of Resident #67's Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 3 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was severely cognitively impaired. Review of a physician progress note dated 10/29/24 indicated the following but not limited to: Glioblastoma multiforme-Decision has been made to make patient comfort measures only and follow up with hospice continue current management. [sic] Review of the physician orders dated 11/11/24 indicated the following: admitted to hospice services as of 11/4/24. Review of the medical record failed to indicate that a significant change MDS was completed within the required time frame following an admission to hospice services. During an interview on 2/13/25 at 10:44 A.M., the Corporate Nurse said a significant change MDS should have been completed for when Resident #67 was admitted to hospice.

Based on observation, record review and interview, the facility failed to accurately reflect the status of one Resident (#42) out of a total sample of 23 residents, when the Minimum Data Set (MDS) assessment failed to indicate that the Resident had an indwelling urinary catheter. Findings include: Resident #42 was admitted to the facility in May 2023 with diagnoses that include neuromuscular dysfunction of the bladder. Review of Resident #42's most recent Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated a Brief Interview for Mental Status score of 15 out of 15 indicating that the Resident is cognitively intact. The MDS failed to indicate the use of an indwelling catheter. On 2/11/25 at 8:00 A.M., Resident #42 was observed lying in bed, a urinary catheter drainage bag was observed hanging from the frame of his/her bed. Review of Resident #42's active Physician's orders indicated the following: -Foley Catheter Order: size: 16 french, 10 balloon Size, dated 5/19/23. -Empty Foley drainage bag and record 24 HOUR output, every night shift for Foley Output (TOTAL OUTPUT), 11/27/24. Review of the January 2025 Treatment Administration Record indicated use of an indwelling urinary catheter for the entire month. Review of Resident #42's active care plan indicated I have a alteration in urinary output r/t (related to) the need for an (specify kind type size balloon size i.e Foley catheter 16 Fr with a 10 ml balloon or Suprapubic) medically justified r/t neurogenic bladder spinal cord disease, dated as revised 8/18/23. [sic] During an interview on 2/12/25 at 12:32 P.M., Nurse #1 said that Resident #42 has an indwelling urinary catheter and had one during the month of January. During an interview on 2/13/25 at 9:47 A.M., the Corporate Nurse said that if a resident had an indwelling urinary catheter, it should be coded accurately on the MDS assessment.

Based on record review and interview, the facility failed to prevent abuse for 1 Resident (#59) from Resident (#18) out of a total sample of 29 residents. Findings include: Review of the facility policy, titled Abuse Prohibition, dated 12/2018, indicated the following: *Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. *Abuse: willful infliction of injury, intimidation resulting in physical harm *Physical abuse: Includes hitting, slapping, pinching, scratching, holding roughly, kicking, etc. It also includes controlling behavior through corporal punishment. Prevention: *Identify, correct, and intervene in situations where abuse, neglect, or mistreatment are more likely to occur. This includes residents/patients with needs and behaviors which might lead to conflict or neglect and sufficient staff and appropriate supervisory staff to identify inappropriate behaviors. Protection: *Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. - Move resident/patient to another room or unit. - Provide 1:1 monitoring as appropriate - Initiate behavior crisis management interventions, as applicable. - Implement discharge process immediately, if resident/patient is in danger to self or to others. Resident #59 was admitted to the facility in March, 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #59's MDS indicated the Resident had no hallucinations or delusions and no behaviors and was totally dependent for care activities. Resident #18 was admitted to the facility in October, 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #18 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the care plan for Resident #18 indicated the following: Focus: I am at risk or have the potential to fall due to wandering behaviors. Interventions: -Please help me decrease agitated states by providing me reassurance (last revised 10/2019) -Please observe me for unsafe behaviors and re-direct me as needed (revised 10/2019) During an interview on 01/31/2022 at 10:20 A.M., Resident #59 said that someone had hit him/her on the shoulder recently with a pink mirror. Review of a progress note, dated 1/23/2022, indicated that Resident #59 reported that he/she was attacked by Resident #18 and that Resident #18 hit Resident #59 on the shoulder. Review of another progress note, dated 1/23/2022, indicated that Resident #18 was slapping Resident #59 and broke a mirror over Resident #59's shoulder. Review of a progress note, dated 1/23/2022, indicated that Resident #18 was involved in a physical altercation with another resident. Resident #18 was removed from the situation and placed on 1:1 continuous supervision and was then sent out via Section 12 (a transportation order to the hospital). Review of a progress note, dated 1/24/2022, indicated that Resident #18 returned from the hospital and remained unchanged, continued to wander on the unit and into other resident's rooms. Resident #18 was unable to be redirected. Review of a progress note, dated 2/3/2022, indicated that Resident #18 went into another resident's room and attempted to throw a chair at another resident then proceeded to enter another resident room and took a shoe and attempted to go after the resident while he/she was in bed. Resident #18 was sent to the hospital. During an interview on 02/03/2022 at 8:25 A.M., Nursing Supervisor #1 said that Resident #18 was on 1:1 for four hours after the incident that occurred on 1/23/2022 and upon his/her return, there were no interventions put into place to prevent a further incident. Nursing Supervisor #1 said that Resident #18 was put on [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) and [MEDICATION(S)] (a medication used to treat Anxiety) in the hospital, but had not been seen by Psych services or had any medication changes upon return from the hospital. Nursing Supervisor #1 acknowledged that Resident #18 did not have any interventions put into place after returning from the hospital after assaulting Resident #59 and subsequently had altercations with two other residents.

Based on observation, record review, and interview, the facility failed to ensure appropriate equipment and assistance were provided for contractures to prevent worsening of range of motion for one Resident (#14) out of a total sample of 19 residents. Findings include: Resident #14 was admitted to the facility in August 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 12/5/2020, indicated Resident #14 was totally dependent for bathing, dressing, hygiene, bed mobility, transfers, and eating. The MDS dated [DATE] further indicated the Resident had impairment in functional range of motion on one side for his/her upper extremities, and did not have any mobility devices. On 3/9/21 at 10:54 A.M., the surveyor observed Resident #14 in his/her bed in his/her room. Resident #14 had contractures to his/her bilateral upper extremities. Resident #14 had a device in his/her right hand, and did not have any devices to his/her left upper extremity. The surveyor did not observe any device for Resident #14's left upper extremity in his/her room. On 3/10/21 at 7:40 A.M., the surveyor observed Resident #14 in his/her bed in his/her room. Resident #14 had a device in his/her right hand, and did not have any devices to his/her left upper extremity. The surveyor did not observe any device for Resident #14's left upper extremity in his/her room. On 3/11/21 at 10:07 A.M., the surveyor observed Resident #14 in his/her bed in his/her room. Resident #14 had no devices on either upper extremity. The surveyor did not observe any device for Resident #14's left upper extremity in his/her room. Review of Resident #14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Occupational therapy plan of care, dated 11/26/19, indicated the following: -Therapy necessary to educate staff on proper donning left hand splint and right elbow splint to increase tissue mobility and prevent further contractures for hygiene. -Resident receives assistance from Certified Nursing Assistants (CNAs) for all Activities of Daily Living (ADL) tasks. -The resident will tolerate right hand splint for 4 hours. -The resident will tolerate left elbow splint for 2 hours. -Staff will be able to don right hand splint and left elbow splint to increase tissue mobility. Review of Resident #14's Occupational Therapy progress notes and discharge summary, dated 1/9/20, indicated the following: -Goal met on 1/9/20, the resident will tolerate hand splint and left elbow splint for 6-8 hours to increase tissue mobility and prevent further skin breakdown to achieve optimum position. -Goal met on 1/9/20, staff will be able to don right hand splint and left elbow splint to increase tissue mobility and prevent skin breakdown for discharge planning to maintenance program. Review of Resident #14's Occupational therapy plan of care, dated 6/3/20, indicated the following: -Resident was evaluated by occupational therapy for splint management. The Occupational Therapy staff educated nursing staff on proper donning/doffing however staff non-compliant with schedule. -Resident presents with bilateral upper extremity contractures. Resident was picked up for occupational therapy on 11/26/19 to 1/9/20 for splinting management - right hand splint and left elbow splint. Staff educated on proper donning/doffing and how long resident is able to tolerate bilateral splints, however, noticed no follow through with the splinting schedule. Review of Resident #14's Occupational therapy plan of care, dated 3/3/21, indicated the following: -Resident with increased bilateral hand contractures. Resident with increased pain and joint contractures with skin breakdown in right palm. Occupational therapy evaluation indicated to increase extensile length and proper splinting program to reduce further deformity, pain, prevent skin breakdown. -Resident with hypersensitivity to left upper extremity unable to fully assess range of motion due to pain. Review of Resident #14's current plan of care indicated the following: -Resident #14 is dependent on staff for all ADL care -Resident #14's plan of care failed to indicate the use of any devices for his/her upper extremities. Review of Resident #14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide a policy or procedure for the use of positioning/splinting devices. On 3/10/21 at 12:10 P.M., Nurse #4 said she did not know if Resident #14 ever used splints for his upper extremities. On 3/10/21 at 1:11 P.M., Nurse #6 said she did not know if Resident #14 ever used splints for his upper extremities. On 3/11/21 at 8:25 A.M., Occupational Therapist (OT) #1 said she evaluated Resident #14 for the first time on 3/3/21. She said she evaluated Resident #14 after observing his/her contractures during her rounds. OT #1 said she was unable to fully evaluate Resident #14's left upper extremity because it was causing him/her pain. On 3/11/21 at 10:09 A.M., Nurse #5 said he did not know if Resident #14 ever used splints for his upper extremities. On 3/11/21 at 10:20 A.M., CNA #6 was unable to recall if Resident #14 had splints for his/her upper extremities. On 3/11/21 at 11:03 A.M., Nurse #2 said she recalled Resident #14 having splints for his bilateral upper extremities when he/she was on the 1st floor unit. She said Resident #14 had the splints because his/her hands curled in. She said Resident #14 moved to the 2nd floor unit with his/her splints a while ago. The facility failed to ensure appropriate equipment and assistance were provided for contractures to prevent worsening of range of motion for Resident #14.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility, positioning and the use of side rails while in bed, the Facility failed to ensure staff implemented and followed his/her plan of care. On 01/07/21, Certified Nurse Aide (CNA) #1, without the assistance of another staff member, assisted Resident #1 with bed mobility and positioning, as he/she rolled over in bed, he/she grabbed on to the side rail, the side rail fell and Resident #1 rolled off the bed and fell on to the floor, as a result his/her gastrostomy tube ([DEVICE], a flexible feeding tube placed through the abdominal wall and into the stomach, used for feeding meals and medications) became dislodged, he/she sustained a left upper eyebrow and left orbital abrasion and was transferred to the Hospital Emergency Department for further evaluation. Findings include: The Facility's Policy titled, Care Planning - Comprehensive, dated April 2010, indicated that the comprehensive care plan was based on a thorough assessment that includes, but was not limited to the Minimum Data Set (MDS). Review of the Facility's Investigation, dated 01/15/21, indicated that on 01/07/21, at 11:00 A.M., while CNA #1, without the assistance of another staff member, went to assist Resident #1 with rolling over in his/her bed, he/she went to grab on to the side rail, the side rail fell , and he/she rolled off the bed and landed on the floor. The Investigation indicated that Resident #1 sustained a bump on his/her forehead, a left upper eyebrow abrasion measuring 0.5 centimeter (cm) x 0.25 cm, a left orbital abrasion measuring 2.5 cm x 0.5 cm, his/her [DEVICE] was pulled out and he/she was transferred to the Hospital Emergency Department for further evaluation. The Investigation indicated that CNA #1 failed to implement Resident #1's Plan of Care while providing Resident #1 assistance with bed mobility and positioning and that his/her side rails were not raised and secured properly prior to his/her fall. Review of Resident #1's Hospital Discharge Summary, dated 01/12/21, indicated that Resident #1 was hospitalized from [DATE] to 01/12/21 and that his/her [DEVICE] had become dislodged during a fall and required surgical intervention for replacement. Resident #1 was admitted to the Facility in February 2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Plan of Care (POC) related to Side Rails, dated as initiated on 03/06/2020 and revised on 09/09/2020, indicated he/she required bilateral quarter side rails as an enabler for positioning and bed mobility. The POC indicated side rails would enable Resident #1 to reposition him/herself, or assist in repositioning with staff assistance, turning from side to side, sit up, lie down, or help him/her exit the bed while maintaining balance. Review of Resident #1's Plan of Care (POC) related to Activities of Daily Living (ADL), dated as initiated on 10/05/20, indicated that he/she was totally dependent on two staff members to assist with bed mobility and positioning. Review of Resident #1's Certified Nurse Aide (CNA) Care Card (also referred to as Kardex), dated 10/26/20, indicated that he/she required bilateral quarter side rails as an enabler, two staff members to provide him/her with extensive assistance for grooming, bathing, dressing, and transfers. The Care Card also indicated that Resident #1 was totally dependent on two staff members to assist him/her with bed mobility and positioning. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was totally dependent on two staff members to assist him/her with bed mobility and positioning. Review of Resident #1's Daily Flow Sheet for Activities of Daily Living, dated 01/01/21 through 01/07/21, indicated that he/she was totally dependent on two staff members to assist him/her with bed mobility and positioning. During an interview on 01/28/21 at 11:30 A.M., and review of the Written Statement, CNA #1 said she assisted Resident #1 with bed mobility and positioning by herself when Resident #1 fell out of bed on 01/07/21. CNA #1 said she was aware that Resident #1 required two staff members for bed mobility and positioning. CNA #1 said Resident #1's side rail was up while she assisted him/her with care but said when Resident #1 grabbed the side rail to roll over, the side rail fell , and he/she rolled off the bed and fell to the floor. During an interview on 01/27/21 at 1:00 P.M., and review of the Written Statement, Nurse #1 said Resident #1 was totally dependent on two staff for bed mobility and positioning due to him/her being quadriplegic. Nurse #1 said she responded to someone (later identified as CNA #1) yelling for help and upon entering Resident #1's room, she saw him/her lying on the floor on his/her left side near his/her bed. Nurse #1 said she assessed Resident #1, provided first aid, called 911 and sent him/her to the Hospital Emergency Department for further evaluation. During an interview on 01/27/21 at 2:45 P.M., the Director of Nursing (DON) said she responded to an overhead page after Resident #1 fell on [DATE]. The DON said she saw Resident #1 lying on the floor with a bump on his/her head and that his/her [DEVICE] became dislodge during the fall. The DON said that after Resident #1's fall, she saw that Resident #1's side rails were in a lowered position on his/her bed and said the side rails should have been raised up and secured on his/her bed during bed mobility and positioning. The DON said CNA #1 failed to implement Resident #1's plan of care which indicated he/she required two staff members to assist with bed mobility and positioning.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility and positioning and the use of side rails while in bed, the Facility failed to ensure staff provided the necessary level of assistance to maintain Resident #1's safety. On 01/07/21, Certified Nurse Aide (CNA) #1, without the assistance of another staff member, assisted Resident #1 with bed mobility and positioning and as Resident #1 rolled over in bed and grabbed onto the side rail, the side rail fell and he/she rolled out of the bed and fell on to the floor, as a result his/her gastrostomy tube ([DEVICE], a flexible tube placed through the abdominal wall and into the stomach used for feeding meals and medications) became dislodged, he/she sustained a left upper eyebrow and left orbital abrasion and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Facility's Policy titled, Falls and Fall Risk, Managing, dated December 2007, indicated that based on previous evaluations and current data, the staff will identify interventions to reduce the risk of falls. The Policy indicated that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Review of the Facility's Investigation, dated 01/15/21, indicated that on 01/07/21, at 11:00 A.M., while CNA #1, without the assistance of another staff member, went to assist Resident #1 with rolling over in his/her bed, he/she went to grab on to the side rail, the side rail fell , and he/she rolled off the bed and landed on the floor. The Investigation indicated that Resident #1 sustained a bump on his/her forehead, a left upper eyebrow abrasion measuring 0.5 centimeter (cm) x 0.25 cm, a left orbital abrasion measuring 2.5 cm x 0.5 cm, his/her [DEVICE] was pulled out and he/she was transferred to the Hospital Emergency Department for further evaluation. The Investigation indicated that CNA #1 failed to implement Resident #1's Plan of Care while providing Resident #1 assistance with bed mobility and positioning and that his/her side rails were not raised and secured properly prior to his/her fall. Review of Resident #1's Hospital Discharge Summary, dated 01/12/21, indicated that Resident #1 was hospitalized from [DATE] to 01/12/21 and that his/her [DEVICE] had become dislodged during a fall and required surgical intervention for replacement. Resident #1 was admitted to the Facility in February 2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Plan of Care (POC) related to Side Rails, dated as initiated on 03/06/2020 and revised on 09/09/2020, indicated he/she required bilateral quarter side rails as an enabler for positioning and bed mobility. The POC indicated side rails would enable Resident #1 to reposition him/herself, or assist in repositioning with staff assistance, turning from side to side, sit up, lie down, or help him/her exit the bed while maintaining balance. Review of Resident #1's Plan of Care (POC) related to Activities of Daily Living (ADL), dated as initiated on 10/05/20, indicated that he/she was totally dependent on two staff members to assist with bed mobility and positioning. Review of Resident #1's Certified Nurse Aide (CNA) Care Card (also referred to as Kardex), dated 10/26/20, indicated that he/she required bilateral quarter side rails as an enabler, two staff members to provide him/her with extensive assistance for grooming, bathing, dressing, and transfers. The Care Card also indicated that Resident #1 was totally dependent on two staff members to assist him/her with bed mobility and positioning. Review of Resident #1's Side Rail Risk Assessment, dated 11/11/20, indicated that side rails would assist him/her with turning side to side during bed mobility, and support during transfers; therefore, bilateral upper side rails on his/her bed were recommended. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was totally dependent on two staff members to assist him/her with bed mobility and positioning. Review of Resident #1's Daily Flow Sheets for Activities of Daily Living, dated 01/01/21 through 01/07/21, indicated that he/she was totally dependent on two staff members to assist him/her with bed mobility and positioning. Review of Resident #1's Nurse Progress Note, dated 01/07/21, indicated that he/she sustained a mechanical fall by rolling out of bed and landing on the floor during ADL care. The Note indicated Resident #1 had a moderate amount of bleeding noted to his/her left upper eyebrow and his/her [DEVICE] was also noted to be pulled out during the fall. During an interview on 01/28/21 at 11:30 A.M., and review of the Written Statement, CNA #1 said she assisted Resident #1 with bed mobility and positioning by herself when Resident #1 fell out of bed on 01/07/21. CNA #1 said she was aware that Resident #1 required two staff members for bed mobility and positioning. CNA #1 said Resident #1's side rail was up while she assisted him/her with care but said when Resident #1 grabbed the side rail to roll over, the side rail fell , and he/she rolled off the bed and fell to the floor. During an interview on 01/27/21 at 1:00 P.M., and review of the Written Statement, Nurse #1 said Resident #1 was totally dependent on two staff for bed mobility and positioning due to him/her being quadriplegic. Nurse #1 said she responded to someone (later identified as CNA #1) yelling for help and upon entering Resident #1's room, she saw him/her lying on the floor on his/her left side near his/her bed. Nurse #1 said she assessed Resident #1, provided first aid, called 911 and sent him/her to the Hospital Emergency Department for further evaluation. During an interview on 01/27/21 at 2:45 P.M., the Director of Nursing (DON) said she responded to an overhead page after Resident #1 fell on [DATE]. The DON said she saw Resident #1 lying on the floor with a bump on his/her head and that his/her [DEVICE] became dislodge during the fall. The DON said that after Resident #1's fall, she saw that Resident #1's side rails were in a lowered position on his/her bed and said the side rails should have been raised up and secured on his/her bed during bed mobility and positioning. The DON said CNA #1 failed to implement Resident #1's plan of care which indicated he/she required two staff members to assist with bed mobility and positioning.

Based on interview and record review, the Facility staff failed to provide treatment and care in accordance with professional standards of practice, for 1 Resident (#46), out of a total sample of 16 Residents. Findings include: Resident #46 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set, dated dated [DATE], indicated that Resident #46 required extensive assistance with activities of daily living including bed mobility, transfers and locomotion. His/her functional limited range of motion showed no impairment to upper extremities (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). He/she scored a 12 out of 15 on the Brief Interview of Mental Status indicating a moderate impairment of cognitive function. Review of the clinical record revealed a nurses note dated 1/26/19 indicating that on the 7:00 [NAME]M.-3:00 P.M. shift Resident #46 was alert and verbally responsive noted sitting in a wheelchair sliding to the right as if trying to get something off the floor. The Resident was unable to sit in the wheelchair. Upon assessment Resident #46 was able to smile, squeeze fingers, and lift the left arm up and the right arm half way up. Vital signs included a blood pressure of 120/75 and a heart rate of 76. The physician was called and staff were awaiting call back. During an interview with Nurse #4 on 3/19/19 at 12:46 P.M., she said that on 1/26/19 Resident #46 was his/her usual self, sitting in a wheelchair, eating breakfast in the dining room. She said at approximately 1:00 P.M., a Certified Nursing Assistant called her into the dining room because Resident #46 kept leaning to the right side. Nurse #4 said she knew the resident needed further evaluation so she called the doctor but he did not call back before her shift ended an hour later. She did not call the physician back despite not receiving a call back. Review of the Facility dated (YEAR), indicated that if the clinical emergency is considered critical then facilitate immediate emergency room transport via 911. Notify the physician and /or medical director in accordance with established guidelines. Upon determination that the clinical presentation warrants immediate physician/ practitioner notification the attending physician is to be called and given 15-20 minutes to respond. Should the attending physician/practitioner not respond another call is made. Should the attending physician practioner not respond in another 15-20 minutes, the Medical Director shall be contacted. Further review of the clincal record revealed a nurse note dated 1/26/19 indicating that on the 3:00 P.M.-11:00 P.M. shift the Resident was noted with right sided weakness at the beginning of the shift, non verbal, not able to move his/her right upper and lower extremities, vital signs included blood pressure of 158/98 and a heart rate of 79. The physician was made aware and gave an order to send the patient to the emergency room for further evaluation. The Resident was sent out at about 6:00 P.M. (Approximately 5 hours after the initial symptoms) During an interview with Nurse #5 on 3/19/19 at 3:45 P.M., she said that during change of shift Nurse #4 said Resident #46 had right sided weakness and was not responding like he normally does, Nurse #4 had called the doctor but had not received a call back. Nurse #5 said she assessed the Resident and called the doctor. When he did not call back she called 911. She said the Resident left the Facility at approximately 6:00 P.M. Review of the hospital discharge summary indicated that Resident #46 arrived at the emergency room as a stroke code. A stat magnetic resonance imaging (MRI) confirmed a hemorrhage (bleeding) in the brain.

Based on interview and record review, the Facility staff failed to provide treatment and care in accordance with professional standards of practice, for 1 Resident (#46), out of a total sample of 16 Residents. Findings include: Resident #46 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set, dated dated [DATE], indicated that Resident #46 required extensive assistance with activities of daily living including bed mobility, transfers and locomotion. His/her functional limited range of motion showed no impairment to upper extremities (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). He/she scored a 12 out of 15 on the Brief Interview of Mental Status indicating a moderate impairment of cognitive function. Review of the clinical record revealed a nurses note dated 1/26/19 indicating that on the 7:00 A.M.-3:00 P.M. shift Resident #46 was alert and verbally responsive noted sitting in a wheelchair sliding to the right as if trying to get something off the floor. The Resident was unable to sit in the wheelchair. Upon assessment Resident #46 was able to smile, squeeze fingers, and lift the left arm up and the right arm half way up. Vital signs included a blood pressure of 120/75 and a heart rate of 76. The physician was called and staff were awaiting call back. During an interview with Nurse #4 on 3/19/19 at 12:46 P.M., she said that on 1/26/19 Resident #46 was his/her usual self, sitting in a wheelchair, eating breakfast in the dining room. She said at approximately 1:00 P.M., a Certified Nursing Assistant called her into the dining room because Resident #46 kept leaning to the right side. Nurse #4 said she knew the resident needed further evaluation so she called the doctor but he did not call back before her shift ended an hour later. She did not call the physician back despite not receiving a call back. Review of the Facility dated (YEAR), indicated that if the clinical emergency is considered critical then facilitate immediate emergency room transport via 911. Notify the physician and /or medical director in accordance with established guidelines. Upon determination that the clinical presentation warrants immediate physician/ practitioner notification the attending physician is to be called and given 15-20 minutes to respond. Should the attending physician/practitioner not respond another call is made. Should the attending physician practioner not respond in another 15-20 minutes, the Medical Director shall be contacted. Further review of the clincal record revealed a nurse note dated 1/26/19 indicating that on the 3:00 P.M.-11:00 P.M. shift the Resident was noted with right sided weakness at the beginning of the shift, non verbal, not able to move his/her right upper and lower extremities, vital signs included blood pressure of 158/98 and a heart rate of 79. The physician was made aware and gave an order to send the patient to the emergency room for further evaluation. The Resident was sent out at about 6:00 P.M. (Approximately 5 hours after the initial symptoms) During an interview with Nurse #5 on 3/19/19 at 3:45 P.M., she said that during change of shift Nurse #4 said Resident #46 had right sided weakness and was not responding like he normally does, Nurse #4 had called the doctor but had not received a call back. Nurse #5 said she assessed the Resident and called the doctor. When he did not call back she called 911. She said the Resident left the Facility at approximately 6:00 P.M. Review of the hospital discharge summary indicated that Resident #46 arrived at the emergency room as a stroke code. A stat magnetic resonance imaging (MRI) confirmed a hemorrhage (bleeding) in the brain.

Based on record review, observation, and interview, Facility staff failed to ensure that 1 Resident (#76) in a total sample of 25, did not sustain approximately 5 skin wounds from self-injurious behavior. The Facility staff failed to secure potentially hazardous materials from resident access. Findings include: 1. Resident #76 hit his/her legs against bed rails that were located in the middle of the bed, not the upper portion of the bed, as indicated in the plan of care. Resident #76 was admitted to the Facility in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. The Surveyor observed Resident #76 on 1/10/19 at 8:30 A.M. Resident #76 was in bed with his/her lower legs hanging over the top of the bed's left side rail. One half of the rail was in the low position and touching the floor. There were no bed side rail pads on the railing. Resident #76's left lower leg shin area had approximately 5 open wounds measuring approximately between 1x1 centimeter to 2x4 centimeters. These wounds were in various stages of healing, including 2 which had scabbed over. The three open wounds did not have a dressing applied, though the Surveyor observed three used dressings on the floor next to the bed. Resident #76 appeared to be in distress but was unable to answer the Surveyor's questions due to his/her impaired cognition. The Surveyor interviewed Unit Manager #1 on 1/11/19 at 1:00 P.M. Unit Manager said that the wounds on Resident #76's lower left leg were caused by him/her hitting his/her legs against the bed rails, and that care plan interventions included a padded side rail. Unit Manager #1 said that Resident #76 had involuntary and voluntary movements and often his/her lower legs hit the rail. Resident #76's Admission Minimum Data Set (MDS) assessment, dated 7/2/18, indicated he/ she was never/rarely understood, did not exhibit behaviors, was totally dependent on staff for bed mobility, did not have any skin wounds, and did not use restraints. Resident #76's care plan for bed side rails, dated 9/25/18, indicated he/she utilized rails to feel safe and secure. Care plan interventions included: at no time should my full side rails be used that restrict me from being able to get in or out of bed, I and my DPOA (Durable Power of Attorney) request the use of 1/4 side rails turning from side to side, sit up, lie down or help me maintaining balance; I have involuntary movement and would like to use rails to minimize the fear of falling out of bed. Resident #76's physician orders, dated 10/15/18 and 11/27/18, indicated he/she had skin wounds on the right shin and left upper leg, which required medicated antibacterial ointments and dressings. Review of the physician's orders [REDACTED].#76's lower left leg wounds, which the Surveyor had observed on 1/10/19. Resident #76's Weekly Skin Check forms, dated 12/3/18, 12/10/18, 12/17/18, 12/24/18 and 1/7/18, indicated he/she had an open area on the right shin. The forms did not reference Resident #76's left lower leg wounds. Resident #76's most recent quarterly MDS assessment, dated 12/20/18, indicated that he/she had skin tear(s), which were treated with non-surgical dressings. Resident #76's nursing note, dated 1/10/19, indicated he/she had a reopened wound with scant amount of serous draining. The note indicated that staff notified the physician, who requested an application of medicated ointment and dressing daily, until healed. The note did not reference the approximately 4 other wounds on Resident #76's left lower leg. 2. The Surveyor observed on 1/11/19 between approximately 9:00 A.M., and 11:30 A.M., the following: The first floor Biohazard Room was unlocked and accessible to residents. The room contained biohazard trash (covered), and three used disposable razors located on top of a sharps container by the entrance door. The Surveyor informed the Consulting Nurse about the unlocked door, who then secured the door and told staff. The ground floor maintenance room was opened fully with no staff in the immediate area. The Surveyor observed tools, screw-drivers, saws, hammers, nails, a grinder and other potential dangerous equipment accessible to residents in the area. The Surveyor told the Administrator about the open maintenance door and he said it was Facility policy to keep the door secured when not in use. The area was accessible to residents. 3. The Surveyor observed on 1/14/19, between approximately 9:00 A.M. and 11:00 A.M., the following: The ground floor the maintenance room door was unlocked with no staff present. The Surveyor told the Administrator that the maintenance door was observed to be unlocked and there were no staff present. The door to the ground floor electrical room, which contained the Facility's circuit breakers, was open and no staff were present. The area was accessible to residents. The ground floor supply room was unlocked and the following was observed inside the the room: * Dozens of bottles of liquid antacid * 16 fl oz bottles of [MEDICATION NAME] sodium * Boxes of [MEDICATION NAME] and zinc sulfate * One 15 ml bottles of hemocult * 8 bottles of sodium hypochlorite * 3 bottles of [MEDICATION NAME] solution * Four 16 oz bottles of liquid Tylenol * Three 16 fl oz milk of magnesia * 6 bottles of aspirin each 121 tabs * 2 pints of [MEDICATION NAME] oral solution * Two 14 oz bottles of [MEDICATION NAME], * 2 boxes containing 5 [MEDICATION NAME]es * 7 boxes containing 14 each of nicotine patches * 4 boxes containing 100 each [MEDICATION NAME] * 1 box of syringes *3 plastic milk crates full of bottles of aspirin The Surveyor observed on 1/15/19 at 8:30 A.M., the second floor Biohazard Room unlocked and accessible to residents in the area. A full sharps container was located by the entry door and a used shaving razor was on the counter.

Based on record reviews and interviews, for one of three sampled residents (Resident #1), who was at risk for skin injury due to the effects of diabetes mellitus, the Facility failed to ensure that on 11/22/13, Physical Therapist (PT) #1 applied a hot pack wrapped in 6 layers of towels with one hot pack cover on Resident #1's left buttock, and not 2 to 3 hot pack covers, per Facility policy. PT #1 did not document the treatment or the condition of Resident #1's skin before or after the treatment, per Facility policy. PT #1 said during the next scheduled physical therapy visit on (11/25/13) Resident #1 reported that she sustained a scald on his/her left buttock and denied contact with any hot surface other than the hot pack treatment on 11/22/13. Nurse Practitioner #1 said Resident #1 had a blister (a second degree burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on his/her left buttock 3 days after the hot pack was applied. Findings include: The Face Sheet indicated that Resident #1 was admitted to the Facility in November 2013 and [DIAGNOSES REDACTED]. Resident #1 had Physician Orders, dated 11/15/13, for a skilled physical therapy evaluation and treatment that included therapeutic exercise, neuro-muscular re-education, therapeutic activities, gait training, and an order for [REDACTED]. The physician's admission history and physical examination [REDACTED]. The Surveyor interviewed Nurse Practitioner (NP) #1 at 8:30 A.M. and at 8:45 A.M. on 1/27/14. NP #1 said she expected physical and occupational therapists to take appropriate precautions and follow policy and procedure when applying a hot pack (direct application of a heat source) for Resident #1 because he/she was at greater risk for skin injury from a direct heat source due to the [DIAGNOSES REDACTED]. The Surveyor interviewed the Director of Rehabilitation at 1:50 P.M. on 1/27/14. The Director of Rehabilitation said the Facility had not used hot packs on residents for approximately two years. The Director of Rehabilitation said it was the policy of the Facility to make sure the hot pack (hydroculator) pack was intact, that the therapist documents the treatment including the resident's response to the treatment, and that appropriate layers of toweling (at least 6 layers of towels) with 2 to 3 hot pack covers on top of each other were used. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. and 4:20 P.M. on 1/27/14. The DON said Resident #1 was the first resident that had a physician's orders [REDACTED]. The DON said during physical therapy on 11/22/13, PT #1 applied a hot pack to Resident #1's left buttock and during the next scheduled physical therapy visit, on 11/25/13, Resident #1 reported that he/she sustained a burn on the left buttock. The Hydrocollator Pack Policy and Procedure indicated that a hydrocollator pack was a physical agent modality responsible for producing moist heat that was slowly released over a period of approximately 30 minutes. The policy also indicated that staff members should take precautions with elderly residents, who may need more toweling due to fragile skin, and should make sure the hot pack was intact. The policy also indicated that staff members should use at least 6 layers of toweling with 2 to 3 hot pack covers on top of each other. The policy also indicated staff must record the treatment through the mobile device and document the area treated, duration of the treatment, and the resident's response to the treatment at a minimum. The Surveyor interviewed Physical Therapist (PT) #1 at 8:15 A.M. on 2/3/14. PT #1 said during the morning therapy session Resident #1 complained of left buttock pain and she applied a hot pack to the left buttock. PT #1 said at the next physical therapy treatment three days later Resident #1 reported he/she sustained a burn on the left buttock from the previous hot pack treatment on 11/22/13. PT #1 said Resident #1 had two blisters on his/her left buttock. PT #1 said she was not aware until after the incident that she needed to use 2 to 3 hot pack covers on top of the six towels. The Director of Rehabilitation said the hydrocollator temperature was 143 degrees Fahrenheit (F.) and the hydroculator policy recommended 140 - 170 degrees F. PT #1 said the hot pack was wrapped in six layers of towels and covered with one hot pack cover and she did not think the hot pack was hot enough to burn Resident #1's skin. PT #1 said Resident #1 had no signs of injury during the first 5 minutes of the hot pack application and she left OT #1 to supervise the treatment because she had another resident waiting for rehabilitation. OT #1 said he agreed to complete Resident #1's hot pack treatment for 10 more minutes as requested. OT #1 said Resident #1 had no redness noted after 5 minutes but said the hot pack was getting hotter and he added one more towel for protection. OT #1 said Resident #1 had no redness noted when the treatment was completed after 10 minutes. PT #1 and OT #1 said they forgot to document the treatment on the mobile device, per the Facility policy. The nurses' notes, between 11/22/13 and 11/25/13, indicated that Resident #1 received scheduled pain management for chronic pain and denied any pain. The Surveyor interviewed Unit Manager #1 at 7:15 A.M. on 1/27/14. Unit Manager #1 said during morning physical therapy, PT #1 came to her to report 2 blisters on Resident #1's left buttock. Unit Manager #1 said she immediately assessed Resident #1 and noted a 2 centimeters (cm) by 1.0 cm fluid filled blister and a 0.5 cm by 0.5 cm fluid filled blister on Resident #1's left buttock. Unit Manager #1 said Resident #1 told her he/she had left buttock pain during morning therapy three days before and PT #1 applied a hot pack to the left buttock for comfort. Unit Manager #1 said Resident #1 denied any other contact with a hot surface other than the hot pack treatment on 11/22/13. Unit Manager #1 said she notified NP #1 that there were 2 blisters noted on Resident #1's left buttock. Unit Manager #1 said, NP #1 ordered a normal saline wash followed by wound gel (treatment for [REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 11/27/13, indicated that Resident #1 was alert, oriented, and had good recall. The MDS indicated that Resident #1 received scheduled pain medication for chronic pain. The Care Area Assessment review report, dated 11/27/13, indicated that Resident #1 was at risk for skin breakdown due to poorly controlled diabetes mellitus that required insulin and he/she sustained a burn on the left buttock described as opened blisters that measured 2.0 centimeters (cm) by 1.0 cm and 0.5 cm by 0.5 cm.