Every finding on record at Care Village at Parkway

Based on observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable/homelike interior on three out of four units. Specifically, the facility's housekeeping and maintenance services failed to clean mice droppings, identify and repair peeled wallpaper, cracked floor tiles, stained and peeling ceilings and gouges in resident rooms. Findings include: A review of the facility policy titled 'Quality of Life-Homelike Environment' with no revision date indicated the following: -Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include cleanliness and order. On 2/25/26 the surveyor observed the following on the Garden 1 (G1) unit: - At 7:25 A.M., mouse droppings throughout the G1 unit, both in resident rooms and in the hallway. - At 7:43 A.M., mouse droppings and a blue pill behind the double doors in the hallway. - At 7:47 A.M., mouse droppings in resident room [ROOM NUMBER] on the floor in the closet. -At 7:47 A.M., mouse droppings in resident room [ROOM NUMBER], and peeling baseboard. -At 8:00 A.M., mouse droppings in resident room [ROOM NUMBER] behind the door. -At 8:06 A.M., mouse droppings and debris in resident room [ROOM NUMBER]'s closet. -At 8:07 A.M., mouse droppings in resident room [ROOM NUMBER] behind bed A. -At 8:19 A.M., resident room [ROOM NUMBER]'s bathroom ceiling, approximately 18 inches in diameter, to be stained brown with a fuzzy black substance and significant peeling of the plaster, tiles missing on the wall and mouse droppings under the radiator. -At 12:49 P.M., the surveyor observed the G1 unit resident's rooms to have evidence of having been mopped. The surveyor also observed that the corners and edges of the rooms still contained the same mouse droppings observed earlier in the morning. -At 12:49 P.M., the surveyor and Unit Manager #2 observed mouse dropping behind the hallway door and along the hallway on the G1 unit. The surveyor and Unit Manager #2 also observed a small round blue pill behind the hallway door. During an interview on 2/25/2026 at 12:49 P.M., Unit manager #2 said that the housekeeper had already cleaned the unit this morning and the mouse droppings and pill should have been cleaned up. On 2/26/26 the surveyor observed the following on the Garden 1 (G1) unit: -At 11:38 A.M., in resident room [ROOM NUMBER]'s bathroom the ceiling was observed to be peeling and to have a black fuzzy substance cracked and missing floor tiles. -At 11:41 A.M., mouse droppings on the floor in resident room [ROOM NUMBER]. -At 11:44 A.M., mouse droppings on the floor in resident room [ROOM NUMBER] as well as cracked floor tiles, and peeling baseboard. -At 11:45 A.M., in resident room [ROOM NUMBER]'s bathroom the surveyor observed bubbled paint on the walls, the sink dirty with enamel around drain worn off. The nightstand with a broken bottom drawer and mouse droppings under radiator. -At 11:48 A.M., in resident room [ROOM NUMBER] behind bed A, the wall was gauged and mouse droppings were observed on the floor. -At 11:52 A.M., mouse droppings on the floor in resident room [ROOM NUMBER] as well as a gauged corner of the wall. In the bathroom the floor tiles were stained and cracked, and the ceiling plaster was cracked, stained brown and peeling. -At 11:55 A.M., the bathroom radiator was rusted and broken with a thick brown substance on the floor under a toilet plunger that was sitting directly on the floor. Mouse droppings were also observed. -At 11:59 A.M., the bathroom in resident room [ROOM NUMBER] had missing wall tiles, the floor tiles were stained brown with a thick brown substance in the corner along with mouse droppings. On 2/26/26 at 7:15 A.M., the surveyor observed the following on the Garden 2 (G2) unit: -Resident room [ROOM NUMBER]: No closet doors, stains on floor -Resident rooms 205 & 207: Have a shared bathroom: The sink constantly running, unable to turn off. Peeling paint off wall tiles. Debris in light fixture making lights cloudy. -Resident room [ROOM NUMBER]: Curtains as closet doors. Cracks in linoleum flooring by bathroom. Sink visibly dirty with unknown substance. Raised toilet chair/set covered in unknown brown staining on seat and legs -Resident room [ROOM NUMBER]: Curtains for closet doors -Resident room [ROOM NUMBER]: Curtains for closet doors. rust marks on radiator. Peeling laminate on overbed table. -Resident room [ROOM NUMBER]: Curtains for closet doors, rubber baseboard molding and pulling away from floor of closet. Peeling paint behind bed C. -Resident room [ROOM NUMBER] Bathroom: raised toilet seat on floor, radiator cover on floor, peeling paint on wall tiles. One side of window screen covered with dust/debris and unable to see out of it. During environmental rounds on 2/26/26 at 7:33 A.M., the surveyor observed the following on the China Garden 1 unit: -Resident room [ROOM NUMBER]: Large water stain on the bathroom ceiling expanding across the room. -Resident room [ROOM NUMBER]: Multiple brown spots were observed expanding across two ceiling tiles above the middle bed. -room [ROOM NUMBER]: The bathroom floor tiles were loose, cracked, and lifted. The floor tiles were covered in a dark brown substance. There were white broken tiles and piles of debris located behind the toilet. -The right of the windowsill had a 3-inch crack with peeling and chipped plaster along the window. The top of the windowsill had plaster that was bulging down and cracked. The there was dark matter observed along the cracked edges. -There was brown discoloration along the floor outside of the bathroom door. -The wall located near the sink was cracked, chipped and had peeling plaster along the bottom approximately 5 inches in length. -The sink/ vanity was chipped, peeling, cracked and had a white substance along the edge and was -The refrigerator seal along the edge inside of the refrigerator was coated with dark gray and black substance. along all of the edges. -The bathroom ceiling had a large dark brown water stain across two tiles. -The ceiling tile located outside of resident room [ROOM NUMBER] had a large brown stain and was chipped. -The Shower Room: There were multipole large brown water stains located across the ceiling tiles. -The shower curtain had multiple dark gray and black spots scattered across the bottom of the curtain and was stained throughout. The following observations and interviews were made in the resident rooms on the Garden 1 (G-1) Unit: -Resident room [ROOM NUMBER]-On 2/25/26 at 8:28 A.M., the Resident in bed A said he/she sees mice at night. Mice droppings were observed underneath the heater. -Resident room [ROOM NUMBER]-On 2/25/26 at 8:24 A.M., the surveyor observed mice droppings next to the dresser on the left side of bed A, behind the main entrance door and behind the headboard of the C bed. The surveyor also observed peeling wallpaper and a gouge on the wall behind the C bed. -Resident room [ROOM NUMBER]-On 2/25/26 at 8:31 A.M., the Resident in bed C said he/she sees mice every night. He/she said the mice come from the hallway. Resident room [ROOM NUMBER]-On 2/25/26 at 8:54 A.M., the Resident in bed A said he/she sees mice at night, he/she said the mice run from the hallway to the closet, and towards the heater. Mice droppings observed in the closet and between the dresser and the closet in the middle of the room. -Resident room [ROOM NUMBER]-On 2/25/26 at 8:34 A.M., the surveyor observed peeling paint on the wall, on the right side, next to the main entrance. Cracked floor tile next to the room entrance. Mice droppings under the heater. The Resident in bed C said he/she has seen mice running from the hallway towards the heater. Resident room [ROOM NUMBER]-On 2/25/26 at 8:39 A.M., mice droppings were observed in the closet, behind the main entrance door, under the heater. The Resident is bed C said he/she sees mice running under the heater at night. During an interview on 2/26/26 at approximately 12:30 P.M., Corporate Nurse #1 said that rounds are completed weekly on the units. Corporate Nurse #1 said that the mouse droppings should have been cleaned by housekeeping. During an interview and observation on 2/26/26 at 8:52 A.M., the Maintenance Director/Housekeeping Director said he was not aware of the peeling walls, cracked floor tile and gouges in the Resident rooms. The Maintenance Director/Housekeeping Director said Resident rooms should not have mice droppings. The Maintenance Director/Housekeeping Director said he is expected to do rounds in all resident rooms, daily, to identify anything that needs repair. The Maintenance Director/Housekeeping Director said that he expects staff to notify him if resident rooms require repair. He said repair concerns should be documented in the maintenance logbook. He said after the repairs are completed, the completion should also be documented in the maintenance logbook as well. The Maintenance Director said he has not been utilizing the Maintenance logbook. He said staff have been communicating with him about other repairs in the facility via WhatsApp. The Maintenance Director/Housekeeping Director said he expects housekeeping staff to move furniture, clean behind doors, and in closets in Resident rooms. He said Resident rooms should not have mice droppings. During an interview on 2/27/26 at 8:28 A.M., the Corporate Nurse said the Maintenance Director is expected to complete rounds daily, identify any repairs, document the repairs needed in the Maintenance logbook, complete the repairs, and document the completed repairs in the Maintenance logbook. The Corporate Nurse said she is aware of the mice problem in the facility. She said that since mice are disease spreading organisms, she expects housekeeping to move furniture, and clean in closets and behind doors. The facility was not able to provide the surveyor any documentation to indicate environmental rounds had been completed.

Based on observations, interviews and record review, the facility failed to have an adequately equipped communication system for one Resident (#1) out of a sample of 32 Residents. Specifically, the facility failed to have a functioning call light.Findings include:Review of the facility policy titled 'Call Light' revised 12/6/21 indicated the following:-Report all defective call lights promptly.Resident #1 was admitted to the facility in April 2024 with diagnoses including polyneuropathy and shortness of breath.Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition.Review of the Resident's Activities of Daily Living (ADL) care plan indicated the following:-Please assist me in toileting. I need 1 staff to assist me. Initiated: 5/1/24.-Please assist me with transfers. I need 1 staff to assist me. Initiated:5/1/24.During an observation and interview on 2/26/26 at 8:04 A.M., Resident #1 told the surveyor that he/she reported to a Nurse and the Maintenance Director months ago that his/her call light was not working. The Resident pressed the call light with the surveyor present, the code alert in the room started to flash, the indicator light outside the resident room did not turn on and no staff responded to the call light.During an interview and observation on 2/26/26 at 8:27 A.M., Nurse #7 and the surveyor pressed the Resident's call light. The code alert started flashing, the light outside and above the Resident's room did not turn on. Both the Surveyor and Nurse #7 walked to the Nurse's station. The Resident's room did not show up on the call light alert screen. Nurse #7 said, when the Resident presses the call light, the code alert in the room starts to flash, the light above the Resident's room turns on and the Resident's room number appears on the call light screen at the Nurse's station. Nurse #7 said the staff respond to the call light and after they have assisted the Resident in the room, they turn off the flashing code alert in the room.During an interview on 2/26/26 at 8:33 A.M., the Maintenance Director said the Resident told him approximately a week ago that his/her call light was not working. The Maintenance Director said he changed the batteries. The Maintenance Director said he was not sure why the call light was not functioning currently. The Maintenance Director said after the Resident told him his/her call light was not working, he did not document the broken call light in the Maintenance log, and he did not document in the Maintenance log that he had fixed the call light.During an interview on 2/27/26 at 8:28 A.M., the Corporate Nurse said all residents' call lights should be functional. The Corporate Nurse said the Maintenance Director is expected to document in the Maintenance log that a call light needs repair and document in the Maintenance log that the call light has been repaired.

Based on record review and interviews, the facility failed to develop a person-centered Post Traumatic Stress Disorder (PTSD) care plan and complete a trauma assessment for one Resident #14 out of a sample of 32 Residents. Specifically, the facility failed to identify the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident.Findings include:Review of the facility policy titled 'Trauma Informed Care' revised 12/6/21 indicated the following:-To identify residents with a history of trauma or PTSD and provide the appropriate care and services.-The facility will ensure that all residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the individuals.-Further, for residents with identified history of trauma or PTSD, the facility will provide appropriate person centered and individualized treatment and services to meet their assessed needs.-Upon admission, a social service/designee will screen all new admissions by using the primary care TSD screen (PC-PTSD) within 5 days of admission.-To prevent triggers that may cause re-traumatization, this screen will not be completed again unless there is an experience that occurs after the initial screen that would trigger a new assessment.Resident #14 was admitted to the facility in August 2019 with diagnoses including PTSD.Review of the Minimum Data Set (MDS) assessment, dated 2/11/26, indicated a Brief Interview for Mental Status (BIMS) Score of 4 out 15 indicating severe cognitive impairment.Review of the Resident's active PTSD care plan indicated the following:Focus-I have a diagnosis of PTSD. Initiated 6/24/23.Goal-I will not experience any new traumatic reactions through the next review. Initiated, 8/26/24.Interventions -identify relationships I can draw from, 1:1 social work or psych support as needed, encourage involvement in recreation, socialization and leisure, encourage me to notify staff if I am feeling or have identified a traumatic response/triggers, psych evaluation and treatment as indicated, report any emergence of signs of isolation, altered mental status or change in behaviors to medical doctor. Initiated, 6/24/23.During an interview and medical record review on 2/27/26 at 7:37 A.M., the Social Worker reviewed the medical record and said a trauma assessment was not completed for the Resident on admission. The Social Worker said this assessment is completed only once. The Social Worker said a trauma assessment should be completed in the electronic health record for all residents admitted with a diagnosis of PTSD. The Social Worker said the trauma assessment provides information to add in the PTSD care plan. The Social Worker reviewed the Resident's PTSD care plan and said it was generic and not person- centered with the Resident's trauma and lacked person centered interventions to mitigate triggers.During an interview on 2/27/26 at 8:46 A.M., the Corporate Nurse said trauma assessments should be completed at admission for residents with a diagnosis of PTSD. The Corporate Nurse said PTSD care plans should be person centered with the Resident's trauma and include person centered interventions to mitigate the Resident's triggers.

Based on observation, record review and interview the facility failed to provide care, consistent with professional standards of practice, to prevent pressure ulcers for one Resident (#78) out of a total sample of 32 residents. Specifically, for Resident #78 the facility failed to elevate heels off of the mattress to prevent the development of pressure ulcers. Findings include:Review of the facility policy titled Pressure Ulcer Prevention, dated revised 12/22/22, indicated that the facility will implement interventions to minimize and/or eliminate contributing factors for pressure ulcer development on patients/resident at risk. Resident #78 was admitted to the facility in July 2024 with diagnoses including diabetes, non-pressure ulcer of the right foot with muscle necrosis and depression. Review of the physician orders dated 10/4/25, indicated an order to elevate legs and float heels when in bed. Review of the facility document titled Norton Scale for Predicting Risk of Pressure Ulcer dated 2/27/23 indicated Resident # 78 is at very high risk for the development of pressure ulcers with a score of 9. Review of the current care plan indicated that Resident #78 will refuse care at times. Further review indicated a focus for history of PVD (peripheral vascular disease) and potential skin breakdown with an intervention to elevate legs and float heels. Review of the treatment administration record failed to indicate Resident #78 refused to have his/her feet elevated off of the mattress. Review of the progress notes dated February 2026 failed to indicate Resident #78 refused to have his/her heels floated as ordered. On 2/25/26 at 7:48 A.M., the surveyor observed Resident #78 lying in bed and to have both heels directly on the mattress. On 2/25/26 at 12:11 P.M., the surveyor observed Resident #78 lying in bed and to have both heels directly on the mattress. On 2/25/26 at 4:05 P.M., the surveyor observed Resident #78 lying in bed and to have both heels directly on the mattress. On 2/26/26 at 7:22 A.M., the surveyor observed Resident #78 lying in bed and to have both heels directly on the mattress. On 2/26/26 at 12:18 P.M., the surveyor and Nurse #7 observed Resident #78 lying in bed and to have both heels directly on the mattress. During an interview on 2/26/26 at 12:18 P.M., Nurse #7 said that it is the responsibility of the nurse and the Certified Nurse's Aide (CNA) to ensure that heels are elevated. Nurse #5 then said that doctor's orders are to be followed and Resident #78's heels should not be on the mattress. During an interview on 2/26/26 at 12:28 P.M., CNA #7 said that she looks at the care plan and the Kardex (a document that informs the CNA's the level of assistance the resident requires as well as any special equipment the resident requires). CNA #7 said that she didn't remember seeing that Resident #78 required his/her heels elevated off of the mattress.

Based on record review and interviews, the facility failed to ensure laboratory services were provided for one Resident (#6) out of a sample of 32 Residents. Specifically, the facility failed to ensure weekly labs were obtained according to the physician's orders. Findings include:Resident #6 was admitted to the facility in July 2023 with diagnoses that included hyperkalemia and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/21/26, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating moderate cognitive impairment. Review of Physician's orders indicated the following:-Please schedule BMP (Basic Metabolic Panel, a common blood test that measures key substances in your blood to assess metabolism, kidney function, and electrolyte balance) labs every Tuesday to be drawn weekly (Wednesday). Document if the resident refuses to have labs done. Alert the provider and DON (Director of Nursing) of any refusal, dated 10/7/25. Review of the Electronic Medical Record (EMR) indicated lab results including a BMP on the following dates:10/8/25, 10/25/25, 10/31/25, 11/8/25, 12/6/25, 1/16/26, 2/13/26. Review of paper medical record failed to include any lab results since 10/7/25. Review of the January 2026 Treatment Administration Record indicated that on 1/6/26 and 1/27/26 a BMP was not scheduled with the lab. Review of the February 2026 Treatment Administration Record indicated that on 2/3/26, 2/10/26, 2/17/26 and 2/24/26 a BMP was not scheduled with the lab. Review of progress notes from 11/24/25- 2/27/26 indicated the following:-A progress note from 2/25/26: Resident refused lab technician to draw [his/her] blood for lab work. Further review of progress notes failed to indicate further documentation that the Resident refused to have labs drawn, or that the physician was aware. During an interview on 2/27/26 at 7:32 A.M., Nurse #5 said that lab results are posted in the EMR or in the labs portal. He said that labs are reviewed with the physician or nurse practitioner when they have resulted. He said that when labs are reported it should be documented in the medical record. Nurse #5 further said that if a resident refuses lab work, then it should be documented in the medical record, and the physician should be notified. During an interview on 2/27/26 at 8:00 A.M., Unit Manager #1 said that lab results are in the facilities EMR but may also be in the labs portal. She reviewed the medical record as well as the lab portal and said that there were no reported labs in the lab portal that were not in the Resident's medical record. She said that the labs should be drawn weekly as indicated in the physician's orders and if the Resident is refusing then it should be documented and the physician should be notified. During an interview on 2/27/26 at 8:57 A.M., the Director of Nurses said that Resident #6 should be having weekly labs as indicated in the physician's orders. She said the Resident has hyperkalemia (elevated potassium levels) and takes a medication to lower it that he/she sometimes refuses. She said it is important to know current potassium levels for the Resident to monitor that it does not get too high. She further said that if the Resident refuses lab work, then the physician should be notified as indicated in the order and it should be documented in the medical record.

Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#106) out of a total sample of 32 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #106. Findings include:Resident #106 was admitted to the facility in January 2020 with diagnoses that included schizophrenia and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/1/26, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated the use of antipsychotic, antidepressant and antianxiety medications. The MDS indicated that antipsychotic medications were received on a daily basis. During an observation and interview on 2/25/26 at 7:51 A.M., the Resident was observed awake in bed. Resident #106 said that he/she was recently made aware that he/she has been sticking his/her tongue out a lot and moving his/her mouth a lot. Resident #106 said that he/she takes antipsychotic medications. On 2/27/26 at 7:19 A.M., the surveyor observed Resident #106 in bed. The surveyor observed involuntary movements of the Residents tongue and mouth. Review of the Behavioral Health note, dated 2/19/26, indicated the following:-Recommend GDR (gradual dose reduction) Risperidone (an antipsychotic medication) due to TD (tardive dyskinesia, a movement disorder that can develop due to certain medications, especially antipsychotics).-Clinical Assessment: tongue protrusion noted.-GDR Rationale: Recommend GDR-Test Scores: Completed today, AIMS (abnormal involuntary movement scale, a test used to assess the severity of dyskinesias, specifically orofacial movements and extremity and truncal movements in patients taking certain medications): score: 7.-Plan/ Recommendations: Recommended to decrease Risperidone to 0.75 mg in the evening. Monitor for tongue protrusion. Monitor for increase in auditory hallucinations. F/up (follow up) in 2 weeks. Review of Resident #106's active physician's orders indicated the following:-Risperdal (Risperidone) 1 mg (milligram), give one tablet by mouth in the evening for schizophrenia, dated as revised 8/17/23. Review of the medical record, including nursing and physician progress notes, failed to indicate that the recommendation was communicated to the physician or provider for review. During an interview on 2/27/26 at 7:35 A.M., Nurse #5 said that whenever recommendations are made from consultants, the nurse is responsible for calling the physician or nurse practitioner to communicate those recommendations. He said the provider in the facility can choose to implement or not implement those recommendations but that it should be documented either way in a progress note. He said recommendations should be communicated to the facility providers within 24 hours. During an interview on 2/27/26 at 8:05 A.M., Unit Manager #1 said that behavioral health sees residents on Thursdays at the facility. She said that any recommendations made must be communicated to and approved by the facility providers. She said within 24 hours of receiving the recommendations they should be reported to the facility providers for approval and it should be documented in a progress note. She said she was not aware of the recommendations for Resident #106 to have a GDR and had not communicated it to the physician. She said especially because he/she is having symptoms as indicated on the AIMS testing it should have been reviewed and implemented immediately. During an interview on 2/27/26 at 8:53 A.M., the Director of Nurses said that when recommendations are obtained from consultants, the nurses must call the physician to verify and confirm the orders. She said that for Resident #106, given the symptoms that he/she is exhibiting, it is concerning to continue the antipsychotic medication as ordered and the recommendations should have been reviewed immediately with the provider.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#10) out of a total sample of 32 residents. Specifically, for Resident #10, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record. Findings include:Review of the facility policy, titled Massachusetts Advance Directives revised 8/3/22 indicated, but was not limited to, the following:-It is the policy of the facility to recognize and support the use of advance directives.-The Nursing Home Administrator is responsible for appointing staff who will initiate conversation to identify residents' responsible parties. Elected staff will confirm that information is appropriately documented in the medical record. Staff will work in accordance with DPH, CMS regulations and MA state law to ensure resident rights, safety and legal needs are met.Resident #10 was admitted to the facility in November 2025 with diagnoses of Wernicke's Encephalopathy and sarcopenia. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #10 had moderate cognitive impairment as evidence by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS).Review of Resident #10's Health Care Proxy (HCP) activation form dated 2/5/25 indicated the Residents HCP was activated as the Resident lacked capacity to make or communicate health care decisions.Review of Resident #10's MOLST form, signed by the HCP on 12/11/25, indicated do not transfer to hospital.Review of Resident #10's MOLST form, signed by the HCP on 1/16/26, indicated transfer to hospital.On 2/25/26, the surveyor observed in the electronic health record, in the clinical dashboard, that Resident #10's Code Status Advance Directive section indicated the following: DO NOT HOSPITALIZE (DNH)/DNI/DNRReview of Resident #10's active physician orders indicated the following order: DO NOT HOSPITALIZE (DNH)/DNI/DNR, initiated 12/22/25.During an interview on 2/25/26 at 3:34 P.M. Nurse #7 said a Residents code status in the electronic medical record (EMR) would be based on the Resident's MOLST form. Nurse #7 said the EMR and MOLST form should match because if something were to happen we (the staff) would know what to do and so that there was not misinformation in different places. Nurse #7 said Resident #10's advance directives were DNH/DNR/DNI (do not hospitalize, do not resuscitate and do not intubate). Nurse #7 reviewed Resident #10's MOLST form, dated 1/16/26, and said that this was the most up to date MOLST form and that it does not match what was in the EMR. Nurse #7 said Resident #10's MOLST form was recently changed. Nurse #7 said the Residents EMR was incorrect and that a nurse or unit manager should have changed it in the EMR by getting a new physician order when the Resident's MOLST form was updated.During an interview on 2/25/26 at 3:42 P.M. Unit Manager #2 said advance directives were based on the wishes of the family in collaboration with a physician and were documented on a MOLST form. Unit Manager #2 said the EMR and MOLST form should be consistent and that they have to match in order to give proper care. Unit manager #2 said Resident #10 was DNR/DNH/DNI; after reviewing the Resident's MOLST form dated 1/16/26 Unit Manager #2 said that it was the most up to date MOLST form and that the Residents advance directives had changed per the HCP's request.During an interview on 2/25/25 at 4:04 P.M. the Social Worker said advance directives were determined by the Resident or HCP if the HCP was activated and that this would be reflected on a MOLST form. After the Social Worker reviewed Resident #10's MOLST form, dated 1/16/26, and the Residents EMR the Social Worker said the EMR was incorrect, that a new MOLST form was completed and that nursing should have changed the advance directives in the EMR. The Social Worker said the risk of having the incorrect advance directive in the EMR is that in an emergency the Resident may not be hospitalized because the code status banner in the EMR was more convenient to review. The Social Worker said that both the EMR and physical MOLST form should be reviewed but that in an emergency situation she could not guarantee that would happen.During an interview on 2/25/26 at 4:26 P.M. the Director of Nursing (DON) said the EMR and MOLST form should be the same and that when a MOLST changes the physician needs to give an updated order.During an interview on 2/26/26 at 8:45 A.M. Corporate Nurse #1 said Resident #10's physician order was wrong and should read may transfer to the hospital and not do not hospitalize as it may not be clear to staff what Resident #10's advance directives were. Corporate Nurse #1 said that when the physician order changes, the code status banner changes automatically.

Based on observation, record review and interview, the facility failed to provide assistance with Activities of Daily Living (ADL) care for two Residents (#81 and #10) out of a total of 32 sampled Residents. Specifically,1. For Resident #81, the facility failed to provide supervision during his/her breakfast meals.2. For Resident #10, the facility failed to remove unwanted facial hair. Findings include: Review of the facility policy, titled Activities of Daily Living, reviewed December 2022, indicated, but was not limited to, the following: -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. -Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that it was unavoidable. -The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. d. Dining - eating, including meals and snacks 1. Resident #81 was admitted to the facility in February 2021 with diagnoses including unspecified dementia, type two diabetes, and essential hypertension. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she had severe cognitive impairment as evidenced by a score of 00 out of a possible 15 on the Brief Interview for the Mental Status Exam. Additional review of the MDS indicated the Resident requires supervision/assistance with eating. Review of Resident #81's Activities of Daily Living (ADL) care plan indicated: Focus: I need assistance/dependent with my ADL's and functional mobility, cognition impairment due to dx (diagnosis) of dementia, dated 10/22/25.Interventions included: I need you to set up and supervise my meals for me to eat. On 2/25/26 at 8:51 A.M., the surveyor observed Resident #81 resting in bed with the curtain pulled. Certified Nursing Assistant (CNA) #1 was present and preparing his/her plate on the overbed table. CNA #1 told Resident #81 to eat and left the room. Resident #81 was not supervised and was not able to be seen from the hallway. On 2/26/26 at 8:38 A.M., the surveyor observed CNA #3 setting up Resident #81's breakfast meal while he/she was in bed and the privacy curtain was pulled. CNA #3 then exited the room. CNA #3 told the surveyor that she is assigned to Resident #81, and he/she is set up for meals and does not require supervision. On 2/26/26 at 8:45 A.M., the surveyor observed Resident #81 eating his/her breakfast meal in bed with the privacy curtain pulled. Although CNA #3 was present in the room, she was assisting Resident #81's roommate with his/her meal, CNA #3 was unable to visualize Resident #81 because of the privacy curtain was pulled. On 2/27/26 at 8:39 A.M., Resident #81 was observed in bed with his/her breakfast meal in front of him/her and the privacy curtain pulled. Although there was a CNA present assisting his/her roommate, she could not visualize Resident #81 because the privacy curtain was pulled. During an interview on 2/27/2026 at 8:44 A.M., Unit Manager #1 said that staff should provide assistance or supervision based on the care plan. Unit Manager #1 said that Resident #81 should have received supervision during the breakfast meals. During an interview on 2/27/26 at 9:37 A.M., the Director of Nursing said that staff should follow the residents' plan of care and provide assistance and supervision as indicated. 2. Resident #10 was admitted to the facility in November 2025 with diagnoses of Wernicke's Encephalopathy and sarcopenia. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #10 had moderate cognitive impairment as evidence by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the Resident required substantial/maximum assistance with personal hygiene, including shaving. Review of Resident #10's ADL care plan indicated the Resident had a self-care performance deficit related to recently impaired mobility, medical conditions and recent hospitalization with the following intervention: -Staff to assist with b grooming, dressing, hygiene, toileting tasks/hygiene, bed mobility, transfers assist, toilet transfer lower dressing dependent, eating set up supervision Resident may use scoop plate during meals' he/she needs assist to dependent with w/c (wheelchair) (sic.), initiated on 11/2/25 and revised 2/9/26. On 2/25/26 at 7:55 A.M. the surveyor observed Resident #10 in his/her room, the Resident had facial hair on his/her chin and upper lip approximately an inch in length. On 2/25/26 at 12:42 P.M. the surveyor observed Resident #10 in his/her room, the Resident had facial hair on his/her chin and upper lip approximately an inch in length. On 2/26/26 at 8:05 A.M. the surveyor observed Resident #10 in his/her room, the Resident had facial hair on his/her chin and upper lip approximately an inch in length. Review of Resident #10's physical and electronic medical record, including a review of the Residents CNA ADL (certified nursing assistant/ activities of daily living) flowsheet, failed to indicate that Resident #10 had refused care. During an interview and observation on 2/26/26 at 2:18 P.M. the surveyor observed Resident #10 in his/her room, the Resident had facial hair on his/her chin and upper lip approximately an inch in length. The Resident said staff had not offered to shave his/her facial hair for a few weeks and that he/she would like to have his/her facial hair shaved by staff. Resident #10 said he/she would not been able to shave his/her own facial hair as he/she did not have feeling in his/her hands. During an interview and observation on 2/26/26 at 2:51 P.M. Nurse #6 said when CNAs see that a resident's facial hair has grown that they would offer to shave it. Nurse #6 said she would not want to have facial hair herself, and she couldn't imagine that anyone else would want it either. Nurse #6 said she would expect refusals of care to be documented, that she was currently Resident #10's nurse and that to her knowledge Resident #10 had not refused care that day. Nurse #6 observed Resident #10's facial hair and said that the Residents facial hair was at a point that staff should have offered to shave him/her, Nurse #6 offered to shave Resident #10's facial hair and Resident #10 agreed. Nurse #6 said Resident #10 would not be able to shave him/herself as he/she could barely hold a cup. During an interview and observation on 2/26/26 at 2:57 P.M. Certified Nursing Assistant (CNA) #7 said CNAs check for, and assist residents with, grooming and bathing every day. CNA #7 said she would let a nurse know if a resident refused care and would try again later. CNA #7 said refusals would be documented on the CNA ADL flowsheet. CNA #7 observed Resident #10's facial hair and offered to shave it, Resident #10 agreed. CNA #7 said she would have expected a CNA to offer to shave Resident #10's facial hair based on how long it was, and that Resident #10 would not be able to do it him/herself. During an interview on 2/26/26 at 3:26 P.M. Unit Manager #2 said whenever a Resident's facial hair needed to be shaved a CNA should offer to shave it and that if a Resident refused care that CNAs have to report the refusal to the nurse and document it in the ADL flowsheet; Unit Manger #2 said the nurse should also write a progress note documenting the refusal. Unit Manager #2 said Resident #10 is usually compliant when offered ADL care. Unit Manager #2 reviewed Resident #10's ADL flowsheet documentation and said that there were no refusals documented for Resident #10. During an interview on 2/26/26 at 3:47 P.M. the Director of Rehab Services (DOR) said that rehab services had not assessed Resident #10's ability to shave and so she would expect a staff member to assist the Resident with shaving as a precaution. During an interview on 2/26/26 at 3:38 P.M. the Director of Nursing (DON) said CNAs should check on residents for grooming needs every day and throughout the day, that if a Resident refused care that the CNAs should let the nurse know of the refusal and that the refusal should be documented.

Based on record review and interview the facility failed to notify the Resident and the resident's representative(s) of the transfer/discharge and the reasons for the move in writing and in a language and manner they understand and failed to provide in writing the facility's bed hold policy, for one Resident (#128) out of one hospitalized resident sampled. Findings include:Review of the facility policy titled Transfer/Discharge Notification, dated September 2019, indicated that the facility will issue residents appropriate transfer/discharge notifications and guidance on their right to appeal, in a manner in which the resident/representative understand. Resident #128 was admitted to the facility in September 2025 with diagnoses including cancer of the stomach and esophagus and severe malnutrition. Review of the progress notes indicated that Resident #128 was discharged to the hospital on [DATE]. Further review failed to indicate a transfer/discharge notice or a bed hold policy was provided to the Resident or the Residents health care proxy.During an interview on 2/26/26 at 11:02 A.M., Corporate Nurse #1 said that she was not able to locate the required transfer/discharge and bed hold policy in Resident #128's medical records. Corporate Nurse #1 also said that both documents should have been provided upon discharge.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing notified his/her physician of a change in condition related to the development a new pressure injury on his/her right heel.Findings include: The Facility's Policy, titled Change in Resident's Condition or Status and Notification, dated as revised 01/01/2020, indicated nursing would notify the Resident's Physician when there had been a significant change in the resident's medical or mental condition or status.The Facility's Policy, titled Skin Body Audit, dated 03/12/13, indicated nursing would perform weekly skin audits on all residents, and any significant abnormal findings would be reported to the resident's physician and family.A deep tissue injury (DTI) is a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to ischemia and subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for timely intervention to prevent progression to more severe wounds.Resident #1 was admitted to the Facility in July 2025, diagnoses included traumatic subarachnoid hemorrhage, dementia, adult failure to thrive, and falls at home.Review of Resident #1's Weekly Skin Assessment, dated 08/28/25, indicated he/she had no open areas or marks on his/her skin.Review of Resident #1's Weekly Skin Assessment, dated 09/04/25, indicated he/she had a quarter sized black dry area on his/her right heel.During an interview on 11/17/25 at 01:10 P.M., Nurse Supervisor #1 said that on 09/04/25 she was assigned to Resident #1's unit on the 03:00 P.M, to 11:00 P.M., shift, completed his/her Weekly Skin Assessment, and said she assessed that he/she had a quarter sized black, dry area on his/her right heel. Nurse Supervisor #1 said the area appeared to be a deep tissue injury (DTI) and said she offloaded Resident #1's heel using pillows. Nurse Supervisor #1 said she notified the nurse who worked the 11:00 P.M., to 07:00 A.M., shift of Resident #1's new pressure injury, but did not notify his/her physician or the on-call physician and did not obtain new orders to treat the pressure injury.Review of Resident #1's Weekly Skin Assessment, dated 09/09/25, indicated he/she had small dry black patches on his/her right heel.Nurse Supervisor #1 said about a week after she had first assessed Resident #1's right heel DTI, she told the Director of Nurses that Resident #1 had the pressure injury, that the physician had not been notified, that there were no treatments ordered, and said she did not notify the Physician at that time either. Nurse Supervisor #1 said she should have notified the physician.Review of Resident #1's Weekly Skin Assessment, dated 09/12/25, indicated he/she did not have any open areas or marks on his/her skin.During an interview on 11/17/25 at 12:44 P.M., Nurse #1 said that he was the nurse assigned to care for Resident #1 on 09/12/25 and said he completed his/her Weekly Skin Assessment. Nurse #1 said Resident # still 1have a blackened area on his/her right heel, but that he did not document it on the Skin Assessment because it was not a new skin abnormality.Review of Resident #1's Medical Record indicated he/she had a significant change in medical condition and was transferred to the Hospital Emergency Department on 09/21/25.Review of Resident #1's Hospital Record, dated 09/21/25, also indicated he/she had a Deep Tissue Injury (DTI) on his/her right heel upon admission to the Hospital.Further review of Resident #1's Medical Record indicated there was no documentation to support that his/her Physician was notified of the pressure injury on his/her right heel.During an interview on 11/17/25 at 08:58 A.M., The Director of Nurses (DON) said Nurse Supervisor #1 should have notified Resident #1's physician or the on-call physician of the new pressure injury on his/her right heel but had not.On 11/17/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 10/02/25, which addressed the area(s) of concern as evidenced by:A. 09/30/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that nursing notifies the physician of any new skin alteration to determine if a treatment order is necessary, that a progress note is written in the resident's medical record documenting this notification including details of any new order.B. 09/30/25, The Regional Director of Clinical Operations conducted a Facility wide audit of all skin assessments.C. 09/30/25, The Regional Director of Clinical Operation ensured that notification was made to the providers of any newly identified skin concerns, and any new orders were implemented.D. 09/30/25, The Director of Nurses (DON)/designee re-educated licensed staff and CNAs to the Facility's policy Change in Condition or Status Notification and educated licensed staff to document a progress note that included physician notification for any Resident change in condition.E. 10/02/25, Resident #1 was re-admitted to the Facility, the Physician was notified of his/her skin alterations, and a Plan of Care was developed and implemented including treatment to his/her right heel pressure injury.F. The DON/designee will conduct daily audits of all skin checks performed to ensure any newly identified skin integrity concerns have been reported to the provider and the notification has been documented in the medical record.G. The DON/designee will bring the results of the audits to the QAPI committee monthly for three months or until the desired outcome is achieved.H. The DON/designee is responsible for ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to have a new pressure injury to his/her right heel, the Facility failed to ensure he/she received treatment and services consistent with professional standards of practice when physician orders for treatment of a new pressure injury were not obtained timely from the provider. Findings include:The Facility's Policy, titled Pressure Ulcer Prevention, dated 12/22/22, indicated the appropriate care and services would be provided to the Facility's residents to assist in the prevention of pressure ulcers and to promote optimal healing. Wounds would be reviewed by the interdisciplinary team and recommendations would be made on a weekly basis.A deep tissue injury (DTI) is a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to ischemia and subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for timely intervention to prevent progression to more severe wounds.Resident #1 was admitted to the Facility in July 2025, diagnoses included traumatic subarachnoid hemorrhage, dementia, adult failure to thrive, and falls at home.Review of Resident #1's Weekly Skin Assessment, dated 08/28/25, indicated he/she had no open areas or marks on his/her skin.Review of Resident #1's Weekly Skin Assessment, dated 09/04/25, indicated he/she had a quarter sized black dry area on his/her right heel.Review of Resident #1's Weekly Skin Assessment, dated 09/09/25, indicated he/she had small dry black patches on his/her right heel.Review of Resident #1's Treatment Administration Record (TAR) for the month of September 2025, indicated that despite identification of new area of pressure to his/her right heel, on his/her weekly skin assessments by nursing on 09/04/25 and 09/09/25, there was no documentation to support the nursing obtained physician's order for the treatment of his/her right heel pressure injury.Review of Resident #1's Medical Record indicated he/she had a significant change in medical condition and was transferred to the Hospital Emergency Department on 09/21/25.Review of Resident #1's Hospital Record, dated 09/21/25, also indicated that he/she had a Deep Tissue Injury (DTI) on his/her right heel upon admission to the Hospital.During an interview on 11/17/25 at 01:10 P.M., Nurse Supervisor #1 said that on 09/04/25 she was assigned to Resident #1's unit on the 03:00 P.M, to 11:00 P.M., shift, completed his/her Weekly Skin Assessment, and said she assessed that he/she had a quarter sized black, dry area on his/her right heel. Nurse Supervisor #1 said the area appeared to be a deep tissue injury (DTI) and said she offloaded Resident #1's heel using pillows. Nurse Supervisor #1 said she did not notify his/her physician or the physician on call to obtain new orders to treat the pressure injury. During an interview on 11/17/25 at 12:44 P.M., Nurse #1 said that he was the nurse assigned to care for Resident #1 on 09/12/25 and said he completed his/her Weekly Skin Assessment. Nurse #1 said Resident #1 did still have a blackened area on his/her right heel. Nurse #1 said he thought Resident #1's physician was aware of the pressure injury, but also said there was no physician's order in place for treatment.During an interview on 11/17/25 at 08:58 A.M., The Director of Nurses (DON) said Nurse Supervisor #1 should have notified Resident #1's physician or the on-call physician to obtain orders for treatment but had not.On 11/17/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 10/02/25, which addressed the area(s) of concern as evidenced by:A. 09/30/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that nursing notifies the physician of any new skin alteration to determine if a treatment order is necessary, that a progress note is written in the resident's medical record documenting this notification including details of any new order.B. 09/30/25, The Regional Director of Clinical Operations conducted a Facility wide audit of all skin assessments.C. 09/30/25, The Regional Director of Clinical Operation ensured that notification was made to the providers of any newly identified skin concerns, and any new orders were implemented.D. 09/30/25, The Director of Nurses (DON)/designee re-educated licensed staff and CNAs to the Facility's policy Change in Condition or Status Notification and educated licensed staff to document a progress note that included physician notification for any Resident change in condition.E. 10/02/25, Resident #1 was re-admitted to the Facility, the Physician was notified of his/her skin alterations, and a Plan of Care was developed and implemented including treatment to his/her right heel pressure injury.F. The DON/designee will conduct daily audits of all skin checks performed to ensure any newly identified skin integrity concerns have been reported to the provider and the notification has been documented in the medical record.G. The DON/designee will bring the results of the audits to the QAPI committee monthly for three months or until the desired outcome is achieved.H. The DON/designee is responsible for ongoing compliance.

Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 05/01/25, nursing staff used a bed sheet wrapped around the Resident #1's chest then tucked it under his/her arms and tied behind Resident #1's wheelchair, to keep him/her from getting up. Findings include: Review of the facility policy titled Physical Restraints, dated December 2022, indicated the facility recognizes each resident's right to be free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat a medical condition. Further review indicated the facility recognizes the necessity of maintaining a systematic method of evaluating and monitoring restraint use and any resident who is utilizing a device that could constitute a restraint will be evaluated to determine if the device is a restraint. Resident #1 was admitted to the Facility in June 2023, diagnoses included parkinsonism, Alzheimer's disease, acute kidney failure, and a history of cerebrovascular accident with right-sided hemiplegia (weakness on one side to upper and/or lower extremities). Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired and had an invoked Health Care Proxy (HCP). Review of the Facility's Internal Investigation, dated 05/01/25, indicated that a staff member reported to the administration that a resident was seen with a sheet wrapped around him/her and then tied to the back of his/her wheelchair. The Resident was identified (as Resident #1), was assessed, no injuries were noted and he/she was found to be in his/her normal state. The Internal Investigation indicated the Facility maintains a surveillance camera system that records various areas of the Facility. The Investigation indicated that the video recording (which has no audio capability) from the dayroom where incident took place, was reviewed. The Investigation indicated Resident #1 was in a wheelchair, was non-ambulatory at the time and had a cast on his/her right lower leg secondary to a past injury. The Investigation indicated that based on review of the camera feed, there were two staff members on duty, (Nurse #1 and Certified Nurse Aide (CNA) #1) at the time of the alleged incident. Review of the surveillance camera video footage clips provided by the Facility, from the overnight shift (11:00 P.M. to 7:00 A.M.) dated 05/01/25 from 5:14:00 A.M. to 6:23:25 A.M., illustrated the following: At 5:14:00, Resident #1 was wheeled into the dining/dayroom by CNA #1. Nurse #1 who was also in the dayroom, can be seen greeting Resident #1 and CNA #1. At 5:14:45, Resident #1 is in his/her wheelchair and positioned in front of a dining table. At 5:15:00, Nurse #1 and CNA #1 ensure Resident #1 is positioned correctly. At 5:16:45, CNA #1 leaves the dayroom, returns shortly with a bed sheet in hand. At 5:17:02, CNA #1 can be seen pulling the sheet apart, holds it up, looks in Nurse 1's direction and Nurse #1 can be seen, shaking her head up and down in a Yes type motion. At 5:17:09, CNA #1 then puts the sheet across the front of Resident #1 under his/her arms and wrapping it behind the wheelchair. Resident #1 is calm, showing no signs of agitation or stress. At 5:17:20, Nurse #1 sits down at the same table as Resident #1, and CNA #1 exits the day room. At 5:17:30, Nurse #1, gets up, offers Resident #1 a box of diversional activities and sits back down at the table. At 5:20:10, Resident #1 can then be seen seen lifting the sheet, which was loose, over his/her head and throwing it behind his/her back. Resident #1 showed no signs of agitation and remained calm. At 5:20:39, Nurse #1, gets up again, places the sheet back around Resident #1, under his/her arms across the abdomen, around to the back of the chair, and then secures it to the back of the wheelchair. Nurse #1 then sits back down at the table and remains with Resident #1. At 6:09:00, Nurse #1 gets up and leaves the dayroom, Housekeeper (HK) #1 enters the room, waves to Resident #1, and goes over to speak to him/her. At 6:09:44, HK #1 sees the sheet wrapped around and tied behind Resident #1's wheelchair, and it looks like she tries to untie it, but does not. From 6:16:00 to 6:17:23, HK #1 remains in the room with Resident 1. HK #1 sees another staff member enter the room, and points to the sheet tied secured behind Resident 1's wheelchair. At 6:20:40, HK #1 can be seen speaking to the Housekeeping Supervisor, who entered the room, and points out the sheet out to him. At 6:21:56, the Housekeeping Supervisor returns to the dayroom with Nurse #1, and he points the sheet the was tied behind Resident #1 out to her, and Nurse #1 can be seen removing the sheet from Resident #1's wheelchair. At 6:23:25, Nurse #1 leaves the room. During an interview on 05/20/25 at 1:10 P.M., Housekeeper (HK) #1 said that she arrived at the unit on 05/01/25 around 6:00 A.M., and one of her first tasks was to clean the dayroom. HK #1 said that when she entered the dayroom, she saw Resident #1 seated at a table, went to greet Resident #1 and noticed there was a bed sheet wrapped around his/her chest, under his/her arms and then tied behind his/her wheelchair. HK #1 said she wondered why the bed sheet was tied behind Resident #1's wheelchair. HK #1 said she was uncertain whether she should untie the sheet and began searching for another staff member for help. HK #1 said that the Housekeeping Supervisor entered the dayroom, so she reported that Resident #1 was restrained in his/her wheelchair and pointed it out to him. During an interview on 05/20/25 at 1:55 P.M., the Housekeeping Supervisor said that on 05/01/25, around 6:20 A.M., he entered the dayroom and Housekeeper (HK) #1 called him over to where Resident #1 was seated in his/her wheelchair at a table. The Housekeeping Supervisor said that HK #1 showed him that a bed sheet was wrapped around Resident #1, and tied behind the back of the wheelchair. The Housekeeping Supervisor said that he reported the incident to Nurse #1, who was at the nurses' station, and then returned with Nurse #1 to the dayroom. The Housekeeping Supervisor said Nurse #1 removed the sheet from Resident 1's wheelchair. During a telephone interview on 05/21/25 at 9:00 A.M., Certified Nurse Aide (CNA) #1 said Resident #1, was up, restless, during the overnight shift (on 05/01/25) and was attempting to get out of bed. CNA #1 said that she assisted Resident #1 into the wheelchair and escorted him/her to the dayroom. CNA #1 said she positioned Resident #1's wheelchair in front of the dining table, and then informed Nurse #1, who was new to the Unit, that Resident #1 was restless and at risk of falling. CNA #1 said she was afraid that Resident #1 would slip forward in his/her chair and hurt his/her leg that was in the cast. CNA #1 said that Nurse #1 had approved and told her it would be okay to use a sheet to prevent Resident #1 from slipping forward, so she lightly wrapped a bed sheet around Resident #1, tucked it behind the wheelchair and loosely secured the ends of the sheet in back of the wheelchair. CNA #1 said she did not believed it was a restraint because Nurse #1 had approved it, that she had not intended to restrain him/her, but only meant to keep Resident #1 safe. The Surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health's telephone call or letter requests for an interview. During an interview on 05/20/25, at 2:40 P.M., the Administrator said that on 05/01/25, the Housekeeping Supervisor reported that Resident #1 had been found with a sheet wrapped around him/her, that was tied to the wheelchair, and it appeared to be a restraint. The Administrator said that he initiated an internal investigation, which included reviewing the Facility's video surveillance camera footage and interviewing staff members on duty during the 11:00 P.M. to 7:00 A.M. shift from April 30, 2025, to May 1, 2025. During an interview on 05/01/25 at 3:41 P.M., the [NAME] President of Clinical Services (VPCS) said that on 05/01/25 when she and Administrator interviewed CNA #1 in person, CNA #1 admitted that she wrapped a sheet around Resident #1's waist, and tied it in back of his/her wheelchair. The VPCS said CNA #1 told them she did it to keep him/her from slipping forward, and that she thought doing this was only way of keeping Resident #1 safe. The VPCS said that CNA #1 reported that, since Nurse #1 was present and approved it, she did not consider it a restraint. The VPCS said when they interviewed Nurse #1 over the phone, Nurse #1 said that She knew nothing about the sheet being on the resident until the Housekeeping Supervisor told her. However, Nurse #1's statement to the facility administration contradicts what was captured on facility surveillance camera footage which shows her shaking her head in a yes type motion when CNA #1 unfolds and shows her the sheet. After Resident #1 pulled the sheet off and threw it behind him/herself, Nurse #1 is the one who is seen reapplying the sheet around Resident #1, tying it in back of his/her wheelchair and then sitting back down at the table where she remained for quite some time, during which the sheet she had secured, was still in place around the resident. The [NAME] President of Clinical Services (VPCS) said that the Facility prides itself on being restraint-free and that Nurse #1 and CNA #1 should not have tied the sheet around Resident #1. The VPCS said that tying a sheet around a resident in his/her chair was not an appropriate safety intervention and that it was considered a restraint. The VPCS said the Facility's investigation substantiated the improper use of physical restraint, and that CNA #1 was reeducated about restraints and Nurse #1 was terminated. On 05/20/25, the Facility was to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was immediately assessed for any sign of injury or distress, none were noted, and he/she remained at baseline. B. Social Services and nursing staff continue to monitor and support Resident #1 for the potential for emotional distress, or adverse reaction to use of a restraint, there have been no changes observed. C. On 05/01/25, all residents on the unit were immediately assessed to ensure no other restraints were in place. D. On 5/02/25, re-education was initiated by Director of Nursing (DON), for all staff on abuse prevention, including but not limited restraints and the appropriate uses of assistive devices for positioning/safety. E. The Interdisciplinary Team (IDT) reviewed the current residents who have positioning needs or who have agitation (or both) to ensure that the staff understand appropriate interventions to use for residents' comfort and safety. F. Starting 05/01/25, daily nursing rounds were initiated and included the need for nursing to check for inappropriate device use. Daily checks by nursing to be continued for the next four weeks, and then continue weekly for four months. The results will be reviewed by the Administrator and the Director of Nursing (DON). G. The results of audits will be presented to the Facility's Quality Assurance and Performance Improvement (QAPI) Committee at monthly meetings for review. H. The Administrator and the Director of Nursing are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of oral hypoglycemic agents for treatment and management of his/her diabetes, the Facility failed to ensure he/she was free from a significant medication error, when on 02/09/25 nursing did not properly identify Resident #1 prior to administering him/her Levemir insulin (a long-acting insulin) via subcutaneous injection. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was admitted to the Intensive Care Unit (ICU) for close monitoring of his/her blood sugars and treatment, as needed. Findings Include: Review of the Facility's Policy titled Medication Administration-General Guidelines, undated, indicated the Following: -medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so -medications are administered in accordance with written orders of the prescriber, -five rights: right resident, right drug, right dose, right route, and right time, -residents are identified before medication is administered using two methods of identification: checking photograph attached to medical record, calling resident by name (except in residents with cognitive impairments), having the resident verify his/her last name, and if necessary, verifying resident identification with other facility personnel. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/14/25, indicated that on 02/09/25 the Director of Nursing (DON) administered 40 units of Levemir insulin (via subcutaneous injection) to Resident #1 in error. The Report indicated that when the DON identified she made the medication error, the on-call provider was alerted, and orders were given to transfer Resident #1 to the Hospital for observation as a precaution. The Report indicated that Resident #1 returned to the Facility the following day, and new orders were given to assess his/her blood glucose levels before meals and at bedtime for three days. Review of an article in Drugs.com the Official Website, dated 03/01/2024, indicated Levemir (detemir) is a man-made form of insulin (a hormone that is produced in the body), that insulin works by lowering levels of glucose (sugar) in the blood, and is used to improve blood sugar control in adults and children with Diabetes Mellitus. The Website indicated Levemir is a long-acting insulin that starts to work several hours after injection and keeps working evenly for up to 24 hours. The Website further indicated an insulin overdose can cause life-threatening hypoglycemia (low blood sugar); symptoms include drowsiness, confusion, blurred vision, numbness or tingling in your mouth, trouble speaking, muscle weakness, clumsy or jerky movements, seizure (convulsions), or loss of consciousness. Resident #1 was admitted to the Facility in June 2024, diagnoses included type 2 diabetes mellitus (non-insulin dependent, the body does not produce enough insulin, or the cells cannot effectively use the insulin that is available), Alzheimer's, hypertension, hyperlipidemia (high cholesterol), and bilateral hearing loss. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment. Review of Resident #1's Medication Error Report, dated 02/09/25, indicated that Resident #1 received 40 units of Levemir insulin in error. The Report indicated Resident #1 was immediately assessed, the on-call Provider was notified, and orders were given to transfer him/her to the Hospital ED for evaluation. Review of Resident #1's Medication Administration Record (MAR), dated February 2025, indicated that he/she did not have a physician's order for Levemir insulin, that he/she received Metformin (oral hypoglycemic, lowers blood sugar) to manage his/her diabetes, and that he/she did not have any orders for administration of insulin. Review of Resident #2's Medication Administration Record (MAR), dated February 2025, indicated that he/she had a physician's order for the following: -Insulin Detemir (brand name Levemir) Solution 100 unit/milliliters (ml), inject 40 unit subcutaneously (under the skin) two times a day at 09:00 (9:00 A.M.) and 21:00 (9:00 P.M.). Review of Resident #1's On-Call Provider Note, dated 02/09/25, indicated that medication was given to Resident #1 in error, he/she was not on insulin, his/her blood sugar was 128 and to transfer him/her to the ED for monitoring and treatment. Review of Resident #1's Progress Note, dated 02/09/25, indicated that Resident #1's blood sugar was 154 at 1:10 P.M., (prior to him/her being sent to the Hospital ED). Review of Resident #1's Hospital Discharge Summary (DC), dated 02/10/25, indicated that Resident #1 presented to the ED for an accidental overdose of insulin. The Summary indicated his/her Diabetes had been managed with diet modification and Metformin, was administered 40 units of Levemir accidentally and brought to the ED for further evaluation. The DC Summary indicated that Resident #1's glucose level was 160 milligrams per deciliter (mg/dl) upon arrival to the ED. The Summary indicated that Resident #1 was initially started on D 10 W (dextrose 10% in water intravenous solution), with Intravenous (IV) fluids, which were stopped and they continued to monitor him/her off the IV fluids. The DC Summary indicated Resident #1 was under observation for insulin overdose, and was admitted to the Intensive Care Unit (ICU). The DC Summary indicated his/her blood glucose checks were to be done every one to two hours, and to hold off on Dextrose (sugar, also known as glucose to treat low blood sugar) administration until his/her blood glucose dips below 100 mg/dl. The DC Summary indicated that Resident #1's blood glucose levels (normal range 74-106 mg/dl) were monitored on 02/09/25 and 02/10/25, with levels dropping (low level) and increasing (high level) and documented as follows: -02/09/25 14:09 (2:09 P.M.) 160 mg/dl -02/09/25 14:15 (2 :15 P.M.) 160 mg/dl -02/09/25 14:17 (2:17 P.M.) 146 mg/dl -02/09/25 15:11 (3:11 P.M.) 135 mg/dl -02/09/25 16:09 (4:09 P.M.) 150 mg/dl -02/09/25 18:03 (6:03 P.M.) 132 mg/dl -02/09/25 20:02 (8:02 P.M.) 169 mg/dl -02/09/25 22:10 (10:10 P.M.) 94 mg/dl -02/10/25 00:19 (12:19 A.M.) 108 mg/dl -02/10/25 02:11 (2:11 A.M.) 84 mg/dl -02/10/25 04:24 (4:24 A.M.) 124 mg/dl -02/10/25 05:50 (5:50 A.M.) 78 mg/dl -02/10/25 06:52 (6:52 A.M.) 91 mg/dl -02/10/25 09:32 (9:32 A.M.) 145 mg/dl -02/10/25 11:39 (11:39 A.M.) 103 mg/dl During an interview on 03/19/25 at 12:31 P.M., Nurse #1 said on 02/09/25, she worked the 7:00 A.M. to 3:00 P.M. shift. Nurse #1 said the Director of Nurses (DON), who was working on another unit, asked her (Nurse #1) for help using the tablet (computer device) so she could contact the on-call provider. Nurse #1 said that the DON told her she (DON) had made a medication error and had administered insulin to the wrong resident (Resident #1). During an interview on 03/20/25 at 2:20 P.M., (which included review of her written statement) the Director of Nursing (DON, now the Former DON) said she worked on one of the nursing units on 02/09/25 because they had no nursing coverage for the 7:00 A.M. to 3:00 P.M. shift. The DON said she was not familiar with the residents on the unit and needed help from the CNA's to identify some of the residents. The DON said Resident #2 was in his/her room that morning, she checked his/her blood sugar and administered his/her insulin coverage, as ordered. The DON said later that morning she asked CNA #1 who Resident #2 was, that CNA #1 pointed to a resident (later identified as Resident #1) who was sitting in the dining room and said she (DON) administered 40 units of Levemir insulin to him/her. The DON said she went to Resident #2's room later to check his/her afternoon blood sugar, and when she went to document the results on his/her MAR, that after looking at his/her photo on the MAR, she realized that she had given the 40 units of Levemir insulin to the wrong resident, and had administered Resident #2's insulin to Resident #1. The DON said Resident #1 was the resident that had been in the dining room earlier that morning, when she had asked a CNA who Resident #2 was. The DON said she notified the on-call provider and obtained an order to send Resident #1 to the Hospital ED for monitoring. The DON said all facility residents have photos on their MARs in Point Click Care (PCC, electronic medical record system) and photos at their bedside. The DON said she had Resident #2's MAR in front of her but could not recall if she looked at the photo on the MAR before she administered the 40 units of Levemir insulin to Resident #1. The DON said she should not have depended on a CNA to identify who the resident was. During an interview on 03/19/25 at 1:00 P.M., (which included review of her interview done by Facility Administration) Certified Nurse Aide (CNA) #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 02/09/25 and the DON was the Nurse on the unit that day. CNA #1 said that the names of the residents on the unit were similar, and that they all had pictures in their rooms so staff could identify them. CNA #1 said the DON asked her a couple times that day to point out and show her who a certain resident was that she was looking for, but said the DON did not ask her (CNA #1) to point out who Resident #1 or Resident #2 was. CNA #1 said Resident #1 always ate his/her breakfast and lunch in the unit dining room and Resident #2 was not in the dining room that day (02/09/25) because he/she liked to stay in his/her room to eat. During an interview on 03/20/25 at 1:51 P.M., (which included review of her interview done by Facility Administration) CNA #2 said she worked the 7:00 A.M. to 3:00 P.M. shift on 02/09/25 and the nurse on the unit that day was the DON. CNA #2 said she knew the residents on the unit by their room numbers, pictures in their room and on their meal trays. CNA #2 said the DON had asked her (CNA #2) to point out who some of the residents were that day because she (DON) said she did not know them. CNA #2 said the DON did not ask her (CNA #2) who Resident #1 or Resident #2 were. During an interview on 03/19/25 at 1:17 P.M., the Director of Infection Control said on 02/09/25 the DON notified her that she (DON) had made a medication error, that she (DON) had administered insulin to the wrong resident (administered Resident #2's insulin to Resident #1) and that Resident #1 was being sent to the Hospital ED for evaluation. During an interview on 03/19/25 at 2:45 P.M., the Director of Operations said she was made aware of the medication error on 02/10/25, that the DON told her (Director) that she had administered insulin to Resident #1 in error. The Director said Resident #1 was a Diabetic, but he/she was not insulin dependent and was only taking an oral medication (Metformin) for diabetes. The Director said her expectation is that nurses follow the rights of medication administration, that nurses properly identifying residents prior to them receiving administration of any medications, and that medication administration is conducted in accordance with facility policy. On 03/19/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 02/10/25, Resident #1 returned to the Facility and his/her blood sugars were monitored before meals and at bedtime for three days. B. On 02/14/25 through 02/18/25, the Corporate Clinical Team completed a house audit on all residents who were receiving insulin to ensure their insulin orders were carried out per Physician orders. C. On 02/14/25, 02/15/25, and 02/17/25, The Assistant Director of Nursing provided education to all Licensed Nursing Staff on the Rights of Medication Administration, the Facility's Policy and Procedure on Medication Administration, and Nursing Care of the Resident with Diabetes Mellitus. D. On 02/18/25, an Ad-Hoc QAPI Committee meeting was held to review Facility Policy, the medication error, corrective actions and plans to be implemented. E. The Corporate Nurse and/or designee will conduct daily audits on medication administration of insulin to ensure there are no medication errors identified for two months, then weekly for four weeks, the audits will continue until overall compliance is achieved. F. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for three months or until compliance is achieved. G. The Assistant Director of Nursing and/or designee are responsible for overall compliance.

Based on observations, record review and interviews, the facility failed to ensure one Resident (#82) was seen by the dentist for routine cleaning and had his/her dentures replaced once missing, out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Dental Services and Denture Services, dated December 2022, indicated the following: -Purpose: To ensure that residents receive routine and emergent dental services to meet their individual needs. -Policy: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Oral heath services are available to meet the resident's needs. -Our facility has a contract with a dentist that comes to the facility and provided dental services on a routine basis. -Nursing services or designee is responsible for scheduling dental services as needed. -Should a resident's dentures become lost or damaged, the facility will refer the resident to a dentist within three (3) days. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. -If the loss or damage of a resident dentures is a result of the facility's actions, the facility will cover the expense of denture repair or replacement in accordance with the established fee schedule with its' contracted dental service provider. Resident #82 was admitted to the facility in November 2022 with diagnoses including stroke, hemiplegia and dysphagia (difficulty swallowing). Review of Resident #82's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #82 required supervision or touching assistance for self-feeding tasks. During an interview on 2/11/25 at 8:04 A.M., Resident #82 said he/she would love to see a dentist for a cleaning and also said his/her top dentures were missing. The Resident said he/she would love to have his/her top dentures replaced. The Resident was observed to only have bottom teeth and the existing teeth were discolored. Review of Resident #82's physician orders indicated the following order: Podiatry, audiology, dental, ophthalmology consults as needed, initiated on 1/18/24. Review of Resident #82's medical record failed to indicate the facility obtained consent for the Resident to be seen by the dentist or had conversations with him/her about having dental visits. Review of Resident #82's admission nursing assessment, dated 11/8/22, indicated the Resident had upper dentures that fit well. Review of the nursing assessment, dated 8/9/24, failed to indicate the Resident had dentures. Review of Resident #82's oral assessment, dated 12/5/24, failed to indicate the Resident had dentures. Review of Resident #82's oral health care plan, last revised 12/5/24, indicated the following intervention: When indicated, I want you to schedule a consult with the dentist for me. During an interview on 2/12/25 at 11:55 A.M., Unit Manager #1 said all residents should have a discussion about ancillary services such as the dentist and consents should be obtained to be treated. During an interview on 2/12/25 at 1:48 P.M., the Assistant Director of Nursing (ADON) said consents for the dentist should be obtained upon admission and as needed. The ADON said she is unaware if Resident #82 ever had dentures and if he/she was ever seen by the dentist and would follow-up. During a follow-up interview on 2/13/25 at approximately 8:30 A.M., the ADON said she was unable to find a consent for dental services for Resident #82 and said she reviewed the nursing assessment which indicated the Resident had been admitted with dentures and is not sure where those dentures are now. During an interview on 2/13/25 at 8:41 A.M., Nurse #3 said she did not know if Resident #82 ever had dentures.

Based on interview, observation, and policy review, the facility failed ensure medications were properly labeled and dated with an expiration, on 1 of 4 nursing units. Findings include: The United States Pharmacopoeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date. Review of the facility policy Storage of Medications, not dated, indicated: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The Nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. On 2/12/25 at 9:52 A.M., on the [NAME] 2 nursing unit, the surveyor observed the medication cart contained the following: - One opened and actively used aerosol inhaler of Budensonide and Formoterol Fumerate Dihydrate (used for the treatment of asthma). The inhaler was not labeled with a resident's name or a date of opening or expiration. - One opened and actively used aerosol inhaler of Albuterol Sulfate. The inhaler did not have a date opened or expiration date. During an interview on 2/12/25 at 9:52 A.M., Unit Manager #1 said that prescription medications including inhalers should be labeled with the resident's name, the date opened and date of expiration.

Based on record review, the facility failed to perform annual performance reviews for three of three sampled Certified Nursing Assistant (CNA) records. Findings include: Review of three out of three CNA employment records indicated that annual performance reviews were not completed as required. During an interview on 2/13/25 at 11:58 P.M., the Regional Administrator said that CNA's should have annual performance evaluations.

Based on observations, record review and interviews the facility failed to provide an activities program to: 1. the residents on the [NAME] 2 Unit, out of four units, and 2. four Residents (#3, #120, #32 and #52) out of a total sample of 27 residents. Findings include: 1. The following observations were made on the [NAME] 2 unit during survey: - The activity calendar failed to list any group activities on the unit for 2/11/25 and no group activities were held on the unit throughout the day on 2/11/25. - On 2/11/25 from 10:00 A.M. to 12:00 P.M. until lunch was served, there were 11 residents sitting in the dining room with the television on. One resident was watching the television, and the rest of the residents were observed sitting in silence at tables without individualized activity materials. Two of the residents were sleeping. Staff were in the room completing their documentation and were not interacting with the residents. There was no activity staff observed on the unit. - On 2/11/25 at 2:14 P.M., there were 10 residents in the dining room. The television was on, but no one was watching it. There was no floor or activity staff in the room. The activity calendar said one-to-one visits were scheduled for this time and they were not occurring. On 02/11/25 at beginning at 3:13 P.M., eight residents were sitting in the dining room. Two staff were present, one was sitting in the corner of the room. The other was in and out and neither were observed engaging with the residents present. The television was on a national news outlet station. One resident was sitting in a wheelchair at a table with two stuffed animals. One resident sat at a table and fidgeted with a water pitcher on the table in front of him/her. The remaining 5 residents were not looking at the television or exhibiting any interest in the news show. One resident was leaning his/her head on his/her hand. The others were staring out or their eyes were closed. - At 3:46 P.M., there were five residents in the dining room and one staff present. One resident was fidgeting with the water pitcher on the table in front of him/her. One resident was sitting with two stuffed animals; one resident was in a wheelchair facing the television and picking his/her nose. One resident was fidgeting with the buttons on his/her sweater. The television was on a national news station. During the observation no residents were engaged, no individual activity supplies were present, nor did the staff present provide any meaningful engagement. - At 3:59 P.M., five residents were seated in the dining room. One staff member was sitting near the corner of the room. One resident was seated at a table with his/her hands folded and looking out of the room. One resident got out of his/her seat and began walking, staff then escorted the resident out of the room. One resident remained seated at the same table with two stuffed animals. The others were sitting. Aside from the television audio there was no interaction observed within the community. - At 4:14 P.M., six residents were in the dining room. One staff member was present. One resident was observed with his/her head leaning on his/her hands. One resident with two stuffed animals was leaning towards the table. The television was on the news and the other residents were sitting and were not observed to be watching the television. - At 4:30 P.M., seven residents were seated in the dining room. The television was on the news. None of the seven residents were looking towards the television or showed interest in the television. One resident was offered and was eating an ice cream. Two staff were present and did not converse, nor engage with the residents present. No activity materials were present for individual interests or pursuits. During an observation on 2/12/25 at 10:05 A.M., review of the posted activity schedule indicated Bible Study at 10:00 A.M. on the G2 unit (Gardener 2) nine residents were in the dining room. One resident was resting his/her head on the stuffed animals on his/her lap while sitting at a table. Shortly after the resident began reaching out to shake a resident's hands who was seated at the table next to him/her. One resident was sitting and holding fake flowers and staring out. Three other residents were seated at a table just staring out, two other residents were seated at table. The television was on a national news network. One staff member was seated in the room and was not interacting with residents in anyway. - At 10:15 A.M. there was no bible study (as listed on the activity calendar), or any other activity occurring in the dining room. 7 residents were seated in the room, one staff member was present and talking with one resident. One resident began walking around the room and then sat back down. A nurse wheeled one resident out of the room. Two residents sitting at a table intermittently reached out for each other and would shake hands and smile. Two other residents were seated at a table and were staring out. Two other residents have their eyes closed. - At 10:21 A.M., One resident stood up and attempted to walk and staff stood up and escorted the resident back to the chair where they were sitting. - At 10:26 A.M., there was no bible study or any activity occurring the dining room. No activity staff were present. There were no activity supplies in the room for individual interest or pursuits. Nine residents were seated in the room. One staff person present. Two residents continued to try to reach out to one another to shake hands. - At 10:33 A.M., one resident stood up and walked out of the room carrying an empty cup, he/she knocked over a wet floor sign and picked it up him/herself. Eight residents remained in the room with no observed engagement. The television was on the news, and no one was watching the television. - At 10:59 A.M., No activities were occurring including Bible Study as posted on the calendar. One resident began putting tablecloths on the tables for lunch. Eleven residents were seated in the room and not engaged in any way. - At 11:16 A.M., nine residents were observed in the dining room. The television was on, and no one was watching it. None of the residents had any individualized activity materials in front of them and there was no social interaction. - At 11:35 A.M., the same nine residents were still in the dining room. There were now staff present in the room, not interacting with any residents. There were no activity materials present. - At 11:50 A.M., one of the Certified Nursing Assistants was observed to have her eyes closed while sitting in the room with the residents. During an observation on 2/13/25 at 10:03 A.M., review of the posted activity calendar on the [NAME] 2 unit indicated 10:00 (A.M.) Music Relaxation and Sensory Games. Eleven residents were seated in the dining room. The television was on a national news network. The residents present were sitting, not engaged and did not have any sensory items or any other activity supplies for their interest for individual pursuits. There was no music playing. - At 10:15 A.M. 12 residents were seated in the dining room, not engaged. Nurse #3 was sitting at a table with residents with a lap top opened and providing some conversation. One resident had his/her hand on his/her head holding it up. One resident entered the room and was talking in a loud repetitive tone consistent with being upset or angry. One resident was at a table with two stuffed animals and not engaged, nor was there any activity occurring per the posted schedule. At this time a rehabilitation staff member entered the room, talked with a few residents including the one resident who had a loud tone. The residents looked up and responded to the rehab staff's brief verbal interaction. The television was changed from news to another station and the residents present did not show interest by looking in the direction of the television. No music relaxation or sensory activity was occurring. During an interview on 2/13/25 at 10:22 A.M., Nurse #3 said she tried to put music on her phone to play for the residents while she was sitting in the room. Nurse #3 said they do not have many activities since the facility was without an activity director for a few months. During an interview on 2/13/25 at 10:32 A.M., an activities staff said he was the Director of the Activities for another building and did not know what the current activity staffing was for this facility, and he is here to help. The activities staff said he would expect the activities listed on the activity calendar to be followed and that residents have engagement. During an interview on 2/13/25 at 9:43 A.M., Nurse #7 said many of the activities listed on the activity calendar do not take place. Nurse #7 said residents have nothing to do. Nurse #7 said residents are not provided supplies for their interest, like fabric for a resident who likes to weave. Nurse #7 said there is no engagement for the residents, which increases them to have behaviors and look vacant and hopeless. During an interview on 2/13/25 at 11:56 A.M., the Activity Assistant said she is primarily responsible for the activities on the [NAME] 1 and 2 units. She said she has been working in the activity department by herself, and she is unable to complete activities throughout the facility and complete one-on-one visits with all the residents with only herself. The Activity Assistant said she attempts to make the activity calendar, but she is unable to hold the groups listed because she cannot be on two units at once. The Activity Assistant said it is the expectation that the nursing staff assist with activities when she is unavailable for the unit, however the staff often do not help with either the transportation for activities or the activities themselves. The Activities Assistant said she is aware activities are lacking for the residents on the [NAME] 2 unit. During an interview on 2/13/25 at 12:18 P.M., the Regional Administrator said they have been without an activities director and interviewing for the position. The Regional Administrator said she recently had staff come from their sister facility to help. The Regional Administrator said she would expect staff to assist residents to attend activities on the G1 floor or engage when they are in the sitting room. 2a. Resident #3 was admitted to the facility in September 2018 with diagnoses including end stage renal disease, diabetes and dementia. Review of Resident #3's most recent Minimum Data Set (MDS) assessment, dated 12/5/24, indicated the Resident scored a 7 out of a possible 15 on the Brief Interview of Mental Status (BIMS) which indicated he/she has severe cognitive impairment. The MDS also indicated the Resident required partial to moderate assistance with functional daily tasks. Review of the MDS dated [DATE], listed the following as the Resident's preferences: - It was somewhat important for the Resident to have books, newspapers, and magazines to read; - It was somewhat important for the Resident to have music to listen to; - It was very important to do things with groups of people; - It was very important to participate in his/her favorite activities; - It was very important to have fresh air; and - It was somewhat important to participate in religious services. During interviews on 2/11/25 at 8:31 A.M., and 2/13/25 at 11:11 A.M., Resident #3 said he/she was very bored in the facility. The Resident said he/she does not get invited to activities, does not know when activities are occurring and would like to attend some if they are of interest to him/her. On 2/11/25 there were no group activities listed on the calendar for Resident #3's unit. No activity staff were observed on the unit running individualized activities and Resident #3 spent the day sitting in his/her room or the lobby of the facility by himself/herself. There were no activity materials observed in the room and the Resident did not have the television or radio on. On 2/12/25 prior to Resident #3 leaving the facility for an appointment, the Resident was observed sitting in his/her room alone. No activity staff were observed on the floor visiting with the Resident. There was no activity materials observed in the room and the Resident did not have the television or radio on. On 2/13/25 Resident #3 spent the day sitting in his/her room or the lobby of the facility by himself/herself. There were no activity materials observed in the room and the Resident did not have the television or radio on. Review of Resident #3's quarterly activities assessment dated [DATE], indicated the following: - The Resident prefers activities in and out of the room; - The Resident's favorite activities are: coffee chat, cooking, baking, drawing, and arts and crafts. Review of Resident #3's activity care plan last revised 11/25/24, indicated the following interventions: - encourage me to participate in ethnic celebrations and family visits; - I need consistent routine with the same activity personnel; - I need cues to assist me with improving stimulation and relaxation; - interview me and/or my family at least quarterly to determine any changes in activity preferences that I may have; - (the Resident) needs a structured activity program for intellectual stimulation and relaxation; - (the Resident) alright yeah needs brief activities as (he/she) has a short attention span; - When I am unable to enjoy group activities provide one to one visits in a quiet location; - When possible and when I can tolerate it I would like community activity. During an interview on 2/13/25 at 11:56 A.M., the Activity Assistant said she has been working in the activity department by herself, and she is unable to complete activities throughout the facility and complete one-on-one visits with all the residents with only herself. The Activity Assistant said Resident #3 enjoys watching cooking shows but was unable to say which type of group activities the Resident would like to attend. The Activity Assistant said Resident #3 does not participate in activities. 2b. Resident #120 was admitted to the facility in October 2024 with diagnoses including dementia and diabetes. Review of Resident #120's most recent Minimum Data Set (MDS) assessment, dated 1/16/25, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated the Resident requires partial to moderate assistance with functional daily tasks. Review of the MDS dated [DATE], listed the following as the Resident's preferences: - It was somewhat important for the Resident to have books, newspapers, and magazines to read; - It was very important for the Resident to have music to listen to; - It was somewhat important to do things with groups of people; - It was very important to participate in his/her favorite activities; - It was somewhat important to have fresh air; and - It was somewhat important to participate in religious services. During an interview on 2/11/25 at 8:27 A.M., Resident #120 said he/she is very bored and would like to attend activities, however staff never invite her or inform her of the activities. On 2/11/25 at 2:10 P.M., the surveyor observed Bingo was occurring in the lobby activity room. At 2:16 P.M., the surveyor observed Resident #120 sitting on the side of his/her bed in a room without lights on. The surveyor informed the Resident that Bingo was occurring, and the Resident said no one informed him/her about Bingo and said he/she would have liked to go and play. Resident #120 said he/she was bored. On 2/12/25 at 1:11 P.M., Resident #120 was observed sitting on the side of his/her bed without the bedroom lights on. The Resident said he/she was bored and was not invited to attend any activities on this day. The Resident was informed that bible study had been on the calendar, and he/she said he/she would have liked to attend that. On 2/13/25, Resident #120 was again observed in his/her dark room and staff were not observed inviting her to the dining room for social engagement or activities. Throughout survey there were no individual activity materials observed in the Resident's room, his/her light was never on, and the television or music was never on. Review of Resident #120's personalized care plans failed to indicate a focused activity care plan had been developed. Review of Resident #120's dementia care plan last revised 11/12/24 indicated the following intervention: - Engage in simple, structured activities that avoid overly demanding tasks. Review of Resident #120's initial activity assessment dated [DATE], indicated the following: - the Resident enjoys cooking and parties, - the Resident prefers the activity room as the place to participate in activities - Resident was cooperative and very social. (He/she) enjoys cooking, parties and going outside. She does go to the activity room period (he/she) enjoys coffee cart and coffee social. Staff will invite (him/her) to cooking and baking programs, on the patio groups, weather permitting. Staff will visit (him/her) in the AM with the daily chronicle and to remind (him/her) of the daily programs with encouragement. During an interview on 2/13/25 at 11:56 A.M., the Activity Assistant said she has been working in the activity department by herself, and she is unable to complete activities throughout the facility and complete one-on-one visits with all the residents with only herself. The Activity Assistant said Resident #120 sleeps a lot and does not participate in activities. The Activity Assistant could not identify activities of interest for Resident #120. 2c. Resident #32 was admitted to the facility in March 2024 and has diagnoses that include but are not limited to adjustment disorder with depressed mood, acute kidney failure, congenital malformation of the heart, and legal blindness. Review of Resident #32's most recent Minimum Data Set (MDS) assessment, dated 12/11/24, indicated Resident #32 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severely impaired cognition and requires supervision with eating and requires substantial/maximal assistance for bathing and transfers. Further review of the comprehensive Minimum Data Set assessment dated [DATE] indicated at Section F, Interview for Activity Preferences the following: - How important is it to you to have books, newspapers and magazines to read? not important at all - How important is it to listen to music you like? Very Important - How important is it to you to be around animals such as pets? Not very important - How important is it to you to keep up with the news? Not very important - How important is it to you to do things with groups of people? somewhat important. - How important is it to do your favorite activities? Very important - How important is it to you to go outside to get fresh air when the weather is good? somewhat important - How important is it to you to participate in religious services or practices? somewhat important. Primary respondent Resident Review of the MDS CAA (care area assessment) Activities analysis of findings indicated Activities: Resident (#32) is at risk for social isolation, d/t (due to) little interest in group activities and verbal behaviors. Review of Resident #32's care plans indicted the following: - I have an alteration in my vision r/t (related to) being legally blind, revised 9/15/2024, with the goal, I will be able to maintain navigate the environment, engage in meaningful activities with your assistance if needed through next review date, target date 5/28/2025. - I wander around with no purpose. I wonder into other resident's residents' rooms, revised 10/2/2024, with associated interventions of Provide activities based on my prior lifestyle and interests, dated 4/3/2024. - I have vision loss, and I am at risk for social isolation, date initiated 3/13/2024, with an associated intervention dated 3/13/2024, I want activities based on my interests and abilities, Inform of the daily activities and help me to activities located out of my room, Please assist me by reading my mail to me and Please supply me with audio materials. During an observation and interview on 2/11/25 at 8:32 A.M., Resident #32 was observed sitting up in a chair eating his/her breakfast. Resident #32 responded to the surveyors greeting. A large box was on his/her bedside table. On 2/11/25 at 3:13 P.M., Resident #32 was observed in the dining room, seated at a table. Resident #32 fidgeted with a water pitcher on the table in front of him her. At 3:46 P.M., Resident #32 remained in the dining room, not engaged and intermittently picked up the water pitcher and fidgeted with it. During an observation and interview on 2/12/25 at 9:08 A.M., Resident #32 was sitting in in his/her room. The television in his/her space was off. A box on his/her bedside table was observed to contain books on tape. Resident #32 said he/she had books on tape but did not know where the player was. The box did not contain the Player, and it was not observed in the vicinity of his/her space. During an interview on 2/13/25 at 9:05 A.M., Certified Nursing Assistant (CNA) #6 said Resident #32 likes to eat, does not see good and likes to listen to the radio. CNA #6 went with the surveyor to Resident #32's room. Resident #32 was sitting in a chair. CNA #6 said where is your radio? Resident #32 said he/she did not know where it was, and he/she wanted to listen to the radio. CNA #6 said the radio plays the books. CNA #6 looked in the box and around his/her room and did not locate the radio (book on tape player). Resident #32 was observed over the past three days without the book on tape player. On 2/13/25 at 9:22 A.M., CNA #6 said she found the radio, (book on tape player) and put it on for the Resident. Resident #32 said this is good. During an interview on 2/13/25 at 11:56 A.M., the Activity Assistant said she has been working by herself trying to provide activities for G 1 and G 2 ([NAME] 1 and [NAME] 2). The AA said she was not sure about the books on tape for Resident #32 and that if he/she has them, staff should assist him/her in using it. AA said if it was missing staff should have helped locate it so it could be used. 2d. Resident #52 was admitted to the facility in February 2017 and has diagnoses that include but are not limited to type 2 diabetes mellitus, unspecified lack of expected normal physiological development in childhood, and unspecified dementia. Review of Resident #52's comprehensive MDS assessment, dated 1/16/25 indicated Resident #52 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severely impaired cognition and requires supervision for eating and assistance from staff for bathing and transfers. Further review of the comprehensive Minimum Data Set assessment dated [DATE] indicated at Section F, Interview for Activity Preferences the following: - How important is it to you to have books, newspapers and magazines to read? Not important - How important is it to listen to music you like? Not very important - How important is it to you to be around animals such as pets? Somewhat important - How important is it to you to keep up with the news? Not important - How important is it to you to do things with groups of people? Not very important - How important is it to do your favorite activities? Somewhat important - How important is it to you to go outside to get fresh air when the weather is good? Not very important - How important is it to you to participate in religious services or practices? Not very important Primary respondent: family or significant other. On 2/11/25 at 8:57 A.M., Resident #52 was observed in bed. He/she was repetitively calling out 'nurse' and pointing to a piece of paper on the floor, which was the daily activity chronicle. A nurse responded and said she would read the chronicle to him/her and the resident smiled. Review of Resident #52's care plans indicated the following: - I have impaired cognition function r/t (related to) dementia, anxiety and depression revision date 5/8/24. Interventions included: Engage me in simple, structured activities that avoid overly demanding tasks, dated 8/6/2019. - I am totally dependent on staff for activities, cognitive stimulation, social interaction r/t cognitive deficits, revision date 10/8/2024. Goal: I will maintain involvement in cognitive stimulation, social activities as desired through review date, target date 1/28/2025. Interventions indicated: I need assistance/escort (sic)activities functions. I preferred arts and crafts, drawing, socials, drawing, and taking my baby dolls with me, invite me to scheduled activities, I prefers (sic) activities which do not involve overly demanding cognitive tasks. Engage is simple, structured activities such as (specify) blank, dated 10/8/2024. On 2/11/25 at 10:00 A.M., review of the posted activity calendar had no activities for [NAME] 1 or [NAME] 2 after 1:30 1:1 visits. At 3:13 P.M., through 4:30 P.M. Resident #52 was sitting in a wheelchair at a table in the dining room. He/she had 2 stuffed animals on his/her lap. There were other residents in the room. At 3:46 P.M., Resident #52 periodically glanced around the room. The television was on a news channel. There was one staff present in the room, sitting with her hands folded on her lap and not providing social interaction. - At 4:14 P.M., Resident #52 remained seated at a table. There were no individualized activity materials in front of the Resident. Resident #52 was leaning in his/her chair with his/her hand on his/her mouth. The television was set to a news channel. Staff did not socially interact or engage Resident #52. On 2/12/25 at 10:05 A.M. review of the [NAME] 2 posted activity calendar indicated Bible Study 10:00 G2 and Word Games and Trivia on G1. On 2/12/25 from 10:05 A.M. through 10:59 A.M., the following observations were made by the surveyor on the [NAME] 2 unit, there were nine residents in the dining room including Resident #52, who was observed seated at a table with his/her head leaned forward resting on the stuffed animals in his/her lap. Shortly after Resident #52 began reaching out to another resident seated at the table and they shook hands. Resident #52 and the resident intermittently reached out to each other to shake hands. At no time did staff offer any engagement, or activity materials to Resident #52. The television remained on a new station and Resident #52 did not exhibit any interest and did not look at the television. During an observation on the [NAME] 2 unit at 2/13/25 10:03 A.M., review of the posted activity calendar indicated 10:00 (A.M.) Music Relaxation and Sensory Games G2. Eleven residents were in the dining room including Resident #52. The television was on a news channel. Resident #52 was seated at a table with two stuffed animals on his/her lap. There was no activity materials, music or sensory items, nor was any structured or non-structured activity or engagement occurring. During an interview on 2/13/25 at 9:43 A.M., Nurse #7 said many of the activities listed on the activity calendar do not take place on [NAME] 2. Nurse #7 said residents have nothing to do. Nurse #7 said residents are not provided supplies for their interest and that she has brought in coloring materials and tries to help engage residents. Nurse #7 said Resident #52 will engage easily, will answer some trivia, and becomes very proud when of him/herself when he/she is involved. During an interview on 2/13/25 at 10:22 A.M., Nurse #3 said she tried to put music on her phone to play for the residents while she was sitting in the dining room. Nurse #3 said they do not have many activities since the facility was without an activity director for a few months. During an interview on 2/13/25 at 11:56 A.M. the Activity Assistant that she covers the [NAME] 1 and [NAME] 2 units and it is a challenge to provide activities since they are without an Activity Director. The Activity Assistant said the residents on [NAME] 2 need someone there to engage them and require more sensory items and liked to do a coloring group. The Activity Assistant said Resident #52 will participate in some activities and will show off his/her personality. 41456

Based on observations and interviews, the facility failed to provide a homelike environment during dining on three of four nursing units. Specifically, on the [NAME] 1, China Garden 1 and China Garden 2 units, residents were observed eating meals on meal trays in the dining rooms. Findings include: The surveyor made the following observations: - On 2/11/25 at 11:50 A.M., the surveyor observed residents eating their lunch on meal trays in the [NAME] 1 dining room. - On 2/11/25 at 12:00 P.M., the surveyor observed residents eating their lunch on meal trays in the China Garden 1 dining room. - On 2/12/25 at 8:20 A.M., the surveyor observed residents eating their breakfast on meal trays in the China Garden 2 dining room. - On 2/12/25 at 8:40 A.M., the surveyor observed residents eating their breakfast on meal trays in the [NAME] 1 dining room. During an interview on 2/12/25 at 8:48 A.M., Certified Nurse Aide (CNA) #8 said the residents normally eat their meals in the dining room off their trays. During an interview on 2/12/25 at 8:52 A.M., Nurse #5 said it is the facility policy for staff to remove resident trays after staff serve their meals. She continued to say this morning's staff forgot to remove the trays. During an interview on 2/12/25 at 9:06 A.M., Nurse #6 said the CNAs are new and they left the breakfast meals on the trays even though they are supposed to be removed from the trays prior to being served. 43846 The surveyor made the following observations: - On 2/11/25 at 8:25 A.M. and 12:15 P.M., the surveyor observed all residents eating their breakfast and lunch on chipped meal trays in the China Garden 1 dining room. - On 2/12/25 at 8:22 A.M., the surveyor observed all residents eating their breakfast on chipped meal trays in the China Garden 1 dining room. During an interview on 2/12/25 at 9:03 A.M., Certified Nurse Aide (CNA) #1 said residents normally eat their meals off the meal tray in the dining room. During an interview on 2/12/25 at 9:05 A.M., Nurse #2 said meal trays should be removed after each resident meal is set up on the table for them and they were not removed today during breakfast. 15016

Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, 1. For Resident #56 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered. 2. For Resident #66 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered. 3. On the [NAME] 2 unit and the China Garden 1 unit, the facility failed to provide a dignified dining experience. 4. On the China Garden 2 unit, the facility failed to provide a dignified dining experience in the dining room. Findings include: Review of the facility policy titled Dignity/Quality of Life, dated 12/6/21, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident #56 was admitted to the facility in June 2020 with diagnoses that included dementia, dysphagia, type 2 diabetes, and major depressive disorder. Review of Resident #56's most recent Minimum Data Set (MDS) assessment, dated 1/2/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated the Resident is dependent on staff for eating. On 2/11/25 from 8:14 A.M. to 8:26 A.M., the surveyor observed Resident #56 in bed with his/her breakfast tray in eye sight not set up for consumption. No staff were present in the room to assist the Resident with their meal. On 2/11/25 from 12:07 P.M. to 12:26 P.M., the surveyor observed Resident #56 in bed with his/her lunch tray within reach not set up for consumption. No staff were present in the room to assist the Resident with their meal. Review of Resident #56's dysphagia care plan, dated 7/17/24, indicated Please do not leave food or drinks in my room unsupervised. I may attempt to eat or drink without supervision which can lead me to choking. Review of Resident #56's activity of daily living care plan, dated 7/17/24, indicated I need your total assistance with eating. I can participate at times. Review of Resident #56's active CNA (Certified Nurse Aide) Kardex (form explaining to staff what level of assistance each resident needs), indicated Total dependence at meal times. During an interview on 2/11/25 at 12:22 P.M., Nurse #1 said the staff are not listening to her to feed the residents who need to be fed. Nurse #1 said the meal trays should not be given to the resident until they are ready to assist them with their meal. Nurse #1 said Resident #56 does need to be assisted with their meals. On 2/13/25 at 11:08 A.M., the Staff Development Coordinator (SDC) said staff should only give a resident a meal once the staff member is ready to assist them with that meal for dignity reasons. 2. Resident #66 was admitted to the facility in April 2019 with diagnoses that included cerebral infraction, dysphagia, bipolar disorder, and paranoid schizophrenia. Review of Resident #66's most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for eating. On 2/11/25 from 8:18 A.M. to 8:27 A.M., the surveyor observed Resident #66 in bed with his/her breakfast tray in eye sight not set up for consumption. No staff were present in the room to assist the Resident with their meal. On 2/11/25 from 12:02 P.M. to 12:22 P.M., the surveyor observed Resident #66 in bed with his/her lunch tray in eye sight not set up for consumption. No staff were present in the room to assist the Resident with their meal. Staff were also observed in the hallway picking up other residents finished meal trays. Review of Resident #66's activity of daily living care plan, dated 2/2/24, indicated I require total assistance from staff with my meals. During an interview on 2/11/25 at 12:22 P.M., Nurse #1 said the staff are not listening to her to feed the residents who need to be fed. Nurse #1 said the meal trays should not be given to the resident until they are ready to assist them with their meal. Nurse #1 said Resident #66 does need to be assisted with their meals. On 2/13/25 at 11:08 A.M., the Staff Development Coordinator (SDC) said staff should only give a resident a meal one the staff member is ready to assist them with that meal for dignity reasons. 45984 3. The following was observed on 2/11/25 at 12:15 P.M., on the [NAME] 2 Unit: - A Nurse was heard referring to residents as feeders outside of dining room within the vicinity of the residents. - A Certified Nursing Assistant was observed assisting a resident with his/her meal while sitting on the arm rest of a chair, not sitting at the level of the resident. The following was observed on 2/11/25 at 12:25 P.M., on the China Garden 1 Unit: - A Certified Nursing Assistant was observed standing while assisting a resident with his/her meal, not sitting at the level of the resident. The following was observed on 2/12/25 at 7:55 A.M., on the China Garden 1 Unit: - A Nurse was heard referring to residents as feeders multiple times outside of dining room within the vicinity of the residents. During an interview on 2/11/25 at 12:30 P.M., the Regional Administration said staff should be seated while assisting a resident with their meal. During an interview on 2/12/25 at 12:32 P.M., Nurse #1 said staff should not refer to residents as feeders for dignity reasons. 4. The following was observed in the China Garden 2 Dining Room: During breakfast service on 2/11/25 the following was observed: - A table containing four residents were served breakfast at 8:21 A.M., 8:30 A.M., 8:33 A.M., and 8:34 A.M. While the last resident was waiting for his/her meal, he/she was signaling to staff by pointing to tablemate's trays, pointing to his/her mouth and waving for his/her food. While the Resident was waiting for his/her food, he/she took another resident's drink, proceeded to drink it and put it back on the tray. The Resident then began eating food from another resident's tray. Staff were in the dining room passing out trays and did not intervene. During lunch service on 2/12/25 the following was observed. - A table containing the same four residents as breakfast on 2/11/25 were served lunch at 12:08 P.M., 12:08 P.M., 12:13 P.M., and 12:17 P.M. While the last resident (the same resident who was served last during breakfast service on 2/11/25) was waiting for his/her meal, he/she was signaling to staff by pointing to tablemate's trays, pointing to his/her mouth and waving for his/her food. While the Resident was waiting for his/her food, the Resident drank a tablemate's juice at 12:14 P.M. At 12:16 P.M., the Resident was signaling to staff for his/her meal, the Resident then opened his/her tablemate's bowl of fruit and began eating it with his/her bare hands and returned the bowl. During an interview on 2/13/25 at 7:37 A.M., the Food Service Director (FSD) said a nurse from the China Garden 2 unit said dining was a mess on Tuesday (2/11/25) morning and they needed to make a new seating chart for the dining room. During an interview on 2/13/25 at 9:45 A.M., Nurse #6 and Unit Manager #2 said they are aware of the Resident taking food and the dining needs to be better. They continued to say that the certified nursing assistants should be supervising residents in the dining room to make sure residents should not be taking food from other residents.

Based on observations and interview, the facility failed to properly store food items to prevent the risk of foodborne illness and ensure food trays and dinnerware were in good condition. Specifically: 1. The facility failed to separate staff's personal food items from resident food items in the walk-in refrigerator and properly label and date food. 2 The facility failed to ensure resident's meal trays and food domes were in good condition. Findings include: 1. During the initial walk-through of the kitchen on 2/11/25 at 7:03 A.M., the surveyor made the following observations in the reach-in refrigerator: - A box of opened, unlabeled, undated donuts with resident food. - A container of unlabeled, undated brown, congealed food in a plastic Tupperware container. - A container of red paste not labeled or dated. During an interview on 2/11/25 at 7:11 A.M., the Food Service Director (FSD) said the donuts and Tupperware of brown material were a staff member's food and they should not be stored with resident food. The FSD continued to say the red paste was a container of ketchup and all food should be labeled and dated. 2. During lunch service on 2/12/25 at 12:42 P.M., the surveyors made the following observations: - The edges and corners of numerous meal trays holding resident food were chipped and worn down. Some of the trays had exposed metal that was underneath the plastic coating on the trays. - The meal domes that cover the resident's meals were very worn down, scratched and rough to the touch. During an interview on 2/13/25 at 7:37 A.M., the FSD said the resident's meal trays and domes should be in good condition and not be cracked or chipped. The surveyor showed the FSD the photos of the meal trays and domes and she said she needs to get new ones.

Based on record reviewed, interviews and observations, for one of three sampled residents (Resident #1), who was severely cognitively impaired, wandered without purpose into other residents room, and therefore resided in a private room, the Facility failed to ensure he/she was free from involuntarily seclusion by being confined to his/her room by staff, when on 11/14/23 from approximately 12:00 A.M. to 1:45 A.M. a bed sheet was tied to the doorknob of Resident #1's room and then tied to the handrail in the hallway outside his/her room, by Certified Nurse Aide #1 who admitted to doing it in order to prevent him/her from exiting his/her room and wandering the unit. Review of Facility video surveillance camera footage showed that Resident #1 had made attempts to open the door during that time, but was unsuccessful. Findings include: Review of Facility Policy and Procedure titled Abuse Prohibition, dated 02/20/23, indicated each resident has the right to be free from involuntary seclusion and will not be subjected to abuse by anyone, including facility staff. The Policy and Procedure indicated residents will be protected from abuse by a combined process that included prevention. The Policy and Procedure indicated to ensure that prevention techniques are implemented in the facility, not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration and stress. Review of Resident #1's clinical record indicated his/her diagnoses included Alzheimer's Disease, Psychotic Disturbance, Major Depressive Disorder, wedge compression fracture of first lumbar vertebra, and unsteadiness on feet. Review of Resident #1's Care Plan, dated 10/27/23, indicated that he/she wandered with no purpose and was oblivious to his/her needs and safety. Care Plan interventions included for staff to check his/her whereabouts frequently, for staff to please remove him/her from other resident's room and unsafe situations, and when he/she began to wander determine need; to go to bathroom, hunger, pain or if cold. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated as completed 11/07/23, indicated he/she had severely impaired cognitive skills for daily decision making, inattention, trouble falling asleep or staying asleep, or sleeping too much, was short-tempered, easily annoyed, ambulated with supervision or touch assistance, required use of walker, and had wandering behaviors that occurred four to six days a week. Review of a photographic image taken on 11/14/23 during the night shift and provided to the surveyor by the Director of Operations, on 11/30/23, indicated that white bed sheet was tied around and encircling the doorknob of Resident #1's closed room door and was also wrapped around the end of a handrail affixed to the adjoining wall in the hallway outside Resident #1's room. Review of the facility video surveillance camera footage starting from approximately 11:30 P.M. on 11/13/23 up until to 2:00 A.M. on 11/14/23, indicated the following: - 11:56 P.M. (on 11/13/23) a staff member (later identified as CNA #1) escorted Resident #1 into a room (located across from the nursing desk, and identified by staff as being Resident #1's room) and the door is closed by CNA #1. - 12:00 A.M. (on 11/14/23) CNA #1 walks away from the room, and then returns holding a bed sheet, CNA #1 unfolds the bed sheet while standing by the closed door. -The door remains closed, CNA #1 can be seen as he ties the bed sheet around the doorknob to Resident #1's room and then loops the bed sheet around the handrail in hallway outside Resident #1's room. - CNA #1 can be seen squatting down, and appears to be pulling and applying force, to secure the bed sheet. - After he applied the bed sheet to the doorknob, CNA #1 walks away. - A few minutes after the bed sheet was applied, Resident #1's room door can be seen being opened inward slightly and closed this happens a few times, in an apparent attempt by Resident #1, who is the only person in the room, to open the door, however he/she was unsuccessful. -During this time there is no response by unit staff (if there was one) captured on surveillance camera footage, as no-one is seen approaching Resident #1's room door from the hallway. - from 12:00 A.M. until approximately 1:45 A.M., while the bed sheet was applied to Resident #1's room door, Nurse #1 can be seen seated at the nursing desk located across from the room, however Nurse #1 is not always visible on the video footage while seated at the desk, as there were four large open binders positioned upright along the upper platform of the desk obstructing the cameras view. -Approximately 1:45 A.M. the Director of Operations enters the Unit and can be seen as she locates Nurse #1 at the nurses desk, Nurse #1 stands up, and CNA #1 can be seen quickly approaching from a hallway from an area on the unit out of the cameras view. -At 1:48 A.M. in what appeared to be under the direction and observation of the Director of Operations, CNA #1 removes the bed sheet from the doorknob and handrail to release Resident #1's door. During a telephone interview on 11/30/23 at 1:30 P.M., Nurse #1 said she arrived on the Unit at approximately 11:00 P.M. on 11/13/23 (for the overnight shift ending at 7:00 A.M. on 11/14/23) to work with CNA #1. Nurse #1 said she was not feeling well and sat at the nursing desk (located across from Resident #1's room). Nurse #1 said Resident #1 does not make any attempts to leave the Unit, but does wander the hallways, enters other resident rooms, touches other residents' belongings and at times the residents will respond by arguing with him/her. Nurse #1 said at the start of the shift, she recalled providing Resident #1 with a drink in the dining room, seeing him/her wander into a resident's room without incident, and hearing CNA #1 verbally redirect Resident #1 back to his/her room. Nurse #1 said she has asked CNA #1 to provide 1:1 supervision for another resident on the Unit that night. Nurse #1 said at approximately 1:30 A.M. the Director of Operations arrived on the Unit and showed her that a bed sheet was tied directly from Resident #1's doorknob to the end of the hallway's handrail. Nurse #1 said CNA #1 admitted he tied the bed sheet and then removed it. Nurse #1 said upon releasing the door, Resident #1 was found to be asleep in bed and appeared to be unharmed. During a telephone interview on 12/01/23 at 2:30 P.M., Certified Nurse Aide (CNA) #1 said during the 11:00 P.M. to 7:00 A.M. shift (on 11/13/23 into 11/14/23), Resident #1 had wandered out of his/her room a few times, despite providing him/her with a snack in the common room and being redirected back to his/her private room. CNA #1 said during the shift the night, Nurse #1 had asked him to provide 1:1 supervision for another resident on the unit. CNA #1 said no one other than Nurse #1 and himself were scheduled to work on the Unit that night. CNA #1 said he was worried Resident #1 would leave his/her room to wander in and out of other resident rooms, that other residents may be disturbed, and feared a potential conflict could result in Resident #1 falling. CNA #1 said at approximately 12:00 A.M. on 11/14/23, he tied a bed sheet from the exterior doorknob of Resident #1's room to the hallway handrail, while Resident #1 was in bed. CNA #1 said he thought the resistance of the bed sheet would cause some banging sounds if Resident #1 tried to open the door, that he would hear it and would then respond to assist Resident #1. CNA #1 said although Nurse #1 was at the nursing desk (across from Resident #1's room), she was busy and was not aware that he had tied the bed sheet to keep Resident #1's door closed. CNA #1 said, after he tied the bed sheet to the doorknob and handrail, he did not hear any sounds to indicate Resident #1 was attempting to open the door to leave his/her room. CNA #1 said he removed the sheet at approximately 1:45 P.M. when the Director of Operations, asked why there was a bed sheet tied from the doorknob to the handrail, and then instructed him to remove it. CNA #1 said upon opening the door Resident #1 was observed to be asleep in bed. During a telephone interview on 12/07/23 at 3:15 P.M., the Director of Operations said she made an unexpected visit to Resident #1's Unit on 11/14/23 at approximately 1:45 A.M. The Director of Operations said Resident #1's door was closed and a bed sheet appeared to be attached to the doorknob. The Director of Operations said she sought out staff, located Nurse #1 at the desk and turned the lights on to further illuminate the Unit. The Director of Operations said she saw more clearly that a bed sheet was tied onto the doorknob and wrapped around the adjoining hallway handrail, which could have impeded Resident #1 from exiting the room. The Director of Operations said Nurse #1 was surprised to see it, and called out for CNA #1 in alarm who quickly approached from down the hallway where he was providing 1:1 supervision for another resident. The Director of Operations said CNA #1 immediately took responsibility for applying the bed sheet to Resident #1's doorknob and handrail, and removed it. The Director of Operations said when Resident #1's room door was opened and he/she was observed to be sleeping. The Director of Operations said CNA #1 stated he was concerned Resident #1 would wander into other resident rooms. The Director of Operations said after speaking to CNA #1, he was immediately removed from the Unit that night. The Director of Operations said although CNA #1 told her he had just applied the sheet prior to her arrival on the unit, said video surveillance footage reviewed by administrative staff at a later date revealed CNA #1 had applied the bed sheet at approximately 12:00 A.M. on 11/14/23. Although Resident #1 was severely cognitively impaired, a reasonable person with intact cognitive functioning would have experienced emotional distress from being involuntarily secluded/confined to his/her room against their will.

Based on observations, record reviews and interviews, the facility failed to prevent a decrease in range of motion for 2 Resident (#46 and #64) out of a total sample of 37 residents. Findings include: 1. Resident #46 was admitted to the facility in February 2015 with diagnoses including dementia. Review of Resident #46's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #46 requires extensive assistance from staff for all functional daily tasks. During all days of survey, Resident #46 was observed lying in bed, with his/her right hand in a fisted position. When asked, Resident #46 was unable to open his/her hand. The Resident was unable to answer any questions about his/her hand. During an interview on 5/21/23 at 11:40 A.M., Resident #46's niece said the Resident's right hand has become increasingly more closed and staff have not attempted treatment or put any orthotic devices in place to prevent the hand from closing more. On 5/23/23 at 9:14 A.M., Certified Nursing Assistant (CNA) #3 attempted to open Resident #46's right hand. As she began to touch the Resident's right hand and attempt to straighten the fingers, Resident #46 yelled out in pain and said, I can't open my hand. CNA #3 was unable to open the Resident's right hand. During an interview on 5/23/23 at 9:10 A.M., Nurse #2 said Resident #46's right hand is more closed and that she had never seen the Resident's hand that bad before. Nurse #2 was unaware if a referral to therapy was ever made. Review of Resident #46's medical record indicated the following: *Resident #46 did not have a neurological diagnosis that would indicate avoidable, progressive contractures. *On occupational therapy evaluation from 8/19/21 which failed to indicate a range of motion deficit of Resident #46's right hand. *All physician and nurse practitioner notes since September 2022 failed to indicate Resident #46 had a deficit in range of motion of the right hand. During an interview on 5/24/23 at 12:21 P.M., the Director of Rehabilitation (DOR) said she completes quarterly screens on all residents in the facility to assess whether they have had a change in function. The DOR said she also depends on nursing to send a referral to the therapy department for any changes in a resident's status. The DOR said Resident #46 has always had a contracture of the right hand but could not say give specifics of the extent of the contracture because previous therapy evaluations did not take measurements of the joint mobility. The DOR said she evaluated Resident #46 herself on 5/23/23 and the Resident's hand did appear to have a worsened contracture and he/she now needs an orthotic to be placed to maintain skin integrity. Review of the occupational therapy evaluation dated 5/23/23 indicated Resident #46 was referred for the evaluation due to a decline in independence with self-feeding. The evaluation indicated Resident #46's right hand contracture limited his/her ability to grasp feeding utensils, causing the decrease in independence with self-feeding. The evaluation also indicated that hand orthotics were now indicated to maintain skin integrity due to the Resident's hand being closed. During an interview on 5/24/23 at 11:45 A.M., Resident #46's Physician said his/her right hand contracture is not new, but it has definitely gotten worse. The Physician said that even though Resident #46 is on hospice services, a referral to therapy would have been beneficial to obtain an orthotic to prevent a worsening contracture or at the very least get a palm protector to preserve skin integrity with a worsening contracture. 36797 2. Resident #64 was admitted to the facility in August 2021 with diagnoses including cervical spine injury and pressure ulcers of the heel and sacrum. Review of the Minimum Data Set (MDS) dated [DATE], indicated a score of 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Further review indicated Resident # 64 is totally dependent on staff for all activities of daily living. On 5/21/23 at 8:20 A.M. and 12:30 P.M., the surveyor observed Resident #64 lying in bed without a hand splint on. The surveyor also observed a blue hand splint on top of Resident #64's bedside table. During an interview on 5/21/23, at 12:33 P.M., Resident #64 said (with daughter translating) nobody has put on the splint today. Resident #64 said that if my daughter doesn't put the splint on then it usually doesn't get put on. Review of the doctor's orders dated May 2023 indicated the following order: Nursing to don left resting hand splint to left forearm wrist and hand for the purpose of contracture management. Pt to wear splint for 6 hours as tolerated with nursing to provide skin check after removal.

Based on observation, interview, and record review the facility failed to provide proper foot care to maintain good foot health resulting in a fungal infection of the right foot and new wound of the left foot for 1 Resident (#73) out of a total sample of 37 residents. Findings include: Review of the facility policy titled, Nursing Care of the Resident with Diabetes Mellitus, not dated, failed to indicate the policy or procedure for performing diabetic foot care. Resident #73 was admitted to the facility in November 2018 with diagnoses including stroke with resulting hemiplegia and hemiparesis affecting the right side, diabetes, and schizophrenia. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #73 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated that Resident #73 is dependent on staff for personal hygiene and bathing. On 5/23/23 at 7:58 A.M., the surveyor observed Resident #73's feet. The surveyor observed a large amount of dry, peeling skin on both feet and the bed beneath the feet. On 5/23/23 at 11:00 A.M., the surveyor observed Resident #73's feet. The surveyor observed a large amount of dry, peeling skin on both feet and the bed beneath the feet. The surveyor then smelled a strong fungal odor coming from the right foot. The surveyor informed the Nurse Supervisor who then asked the Nurse Practitioner (NP) to inspect Resident #73's feet. The surveyor observed the NP wipe between the toes of Resident #73's right foot with a 4 x 4 gauze pad. The surveyor observed a thick, brownish, moist substance on the 4 x 4 gauze after the NP cleaned between each toe. During an interview on 5/23/23 at 11:00 A.M., the NP said that the right foot smelled, and looked like, there was a fungal infection between the toes. The NP also said that diabetic foot care should consist of cleaning between the toes, drying them thoroughly and keeping something like gauze or lambswool between the toes to keep them dry and separated to help prevent a fungal infection from occurring. The NP then said that a thick cream should then be applied to the feet to prevent the peeling and cracking of the skin. Review of the physician orders dated May 2023 indicated an order to provide diabetic foot care every day at HS (hour of sleep). Document adverse findings and notify MD (doctor). Review of the care plan dated as revised 1/25/23, indicated Resident #73 is dependent on staff for personal hygiene. Further review failed to indicate to provide diabetic foot care daily and failed to indicate that Resident #73 refuses care. Review of the medical record failed to indicate a history of foot fungus. During an interview on 5/23/23 at 12:30 P.M., Resident #73 said that the nurse's do not provide diabetic foot care. Resident #73 said that sometimes the Certified Nurse's Assistants (CNA)'s will wash between the toes but not very often. Resident #73 also said that nothing is ever put between the toes to keep them seperated and dry. During an interview on 5/24/23 at 11:50 A.M., the Medical Director said that the foot smelled and looked like there was a fungal infection between the toes. The Medical Director then said that the fungal infection requires being treated with an anti-fungal medication. The Medical Director then said that the reason that Resident #73 developed a fungal infection was because of poor hygiene. On 5/25/23 at 7:10 A.M., the surveyor observed Resident #73 lying in bed. Resident #73's right foot had copious amounts of dry flaking skin with flakes of skin covering the blue bootie his/her foot was lying on top of. Nothing was observed between the toes to separate them. During an interview on 5/25/23 7:13 A.M., CNA #10 said that the nurse's are responsible for providing diabetic foot care and it should be done every night and the toes should be kept separated. CNA #10 said that she has never seen anything between the toes to keep the area dry and seperated. Review of the wound care note dated 5/25/23, indicated Resident #73 has a new open wound on the left big toe and the cause of the wound is infection. During an interview on 5/25/23 at 11:05 A.M., the Wound Physician said that Resident #73 has a fungal infection on the right foot between the toes and on the left foot. The Wound Physician said the fungal infection needs to be treated before he can treat the open areas on the Resident's toes. The Wound Physician said that he would be recommending to the Resident's primary doctor to start an antifungal treatment.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was receiving Hospice Services related to end of life care needs, the Facility failed to ensure that based on his/her comprehensive assessment that care needs were provided in accordance with acceptable standards of practice. When on [DATE] at approximately 2:00 P.M. Resident #1 was noted to experience a decline in condition with changes in his/her respiratory status, Hospice was notified, and Physician's Orders were obtained to administer liquid morphine (opioid used for respiratory distress and moderate/severe pain). However, despite Resident #1's continued decline and noted respiratory distress, nursing waited for his/her morphine to be delivered from the pharmacy, and did not try to access the Facility's emergency kit to obtain the medication, which resulted in an unnecessary delay in Resident #1 being administered morphine which was ordered to help alleviate his/her respiratory distress. Findings include: Review of Facility Policy titled Hospice Program, dated as last revised [DATE], indicated when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. Review of Facility Policy titled Preparation and General Guidelines for Medication Administration, dated [DATE], indicated if medications with a current , active order cannot be located in the medication cart, other areas of the medication cart, medication room, and facility (other units) are searched, if possible. The Pharmacy is contacted, or the medication is removed from the emergency kit. Resident #1 was admitted in February 2020, diagnoses included lung cancer, chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, and anemia. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was admitted on to Hospice Services. Review of Resident #1's Care Plan titled, Hospice Care, dated [DATE], indicated his/her goal was to have a peaceful death with a tolerable pain level. The Care Plan also indicated interventions included nursing to administer medications for pain and discomfort that Hospice has recommended and per Physician's Order, and the Nursing Facility will work with Hospice Staff to ensure Resident #1's needs are met. Review of Resident #1's Care Plan titled, Chronic Obstructive Pulmonary Disease (COPD), indicated that he/she would display optimal breathing patterns. During an interview on [DATE] at 10:18 A.M., Resident #1's Health Care Agent (HCA) said on [DATE], she arrived at the Facility at approximately 4:30 P.M., to find Resident #1 struggling to breathe, that he/she was gasping for air, and was making gurgling sounds. The HCA said she went to the nurses station, spoke to Nurse #1 and asked about oxygen and morphine for Resident #1. The HCA said she went back to the nurses station about 20 minutes later and that Nurse #1 said they were working on it. The HCA said the Hospice Chaplin arrived at 5:00 P.M., and said that he went to the nurses station to ask about Resident #1's morphine and oxygen. The HCA said approximately 20 minutes later, a certified nurse aide (not a nurse) came into the room, placed oxygen on Resident #1, and left the room. The HCA said from the time she first got to the facility that day (4:30 P.M.) to be with Resident #1, that no-one from the facility, not even his/her nurse, came into the room to assess Resident #1. The HCA said it was not until the Hospice Nurse arrived at 6:20 P.M., that anyone did anything to help Resident #1. The HCA said it was heartbreaking to see the way Resident #1 died , that it was a horrible experience. Review of Resident #1's Nursing Progress Note (written by Nurse #1), dated [DATE], indicated he/she was having some changes around 11:00 A.M., some abnormal vitals, restlessness, and shortness of breath. Review of Resident #1's Nursing Progress Note (written by Nurse #2), dated [DATE], indicated Resident #1 was having some respiratory distress, called Hospice for recommendations, and called Resident #1's HCA to inform her of his/her change in condition. During an interview on [DATE] at 1:50 P.M., the Hospice Case Manager (CM) said she received a call from Nurse #2 regarding Resident #1 at approximately 3:00 P.M. The Hospice CM said Nurse #2 informed her that Resident #1 was declining and requested comfort medications. The Hospice CM said she provided Nurse #2 with the recommendations and said she asked Nurse #2 if she should come into the Facility to see Resident #1, and that Nurse #2 said no. Review of Resident #1's Physician's Orders, dated [DATE] at 2:18 P.M., indicated he/she was to receive Morphine Sulfate Solution 20 milligrams (mg) per milliliter (ml), give 0.25 ml sublingually (under the tongue) every six hours and as needed (PRN). During an interview on [DATE] at 4:28 P.M., Nurse #1 said she tried to call the pharmacy multiple times to get Resident #1's morphine. Nurse #1 said she did not think of accessing the Emergency (E) Kit. During an interview on [DATE] at 2:15 P.M., the Pharmacy Manager said the pharmacy received the fax for Resident #1's morphine at 3:09 P.M. The Pharmacy Manager said the authorization code to open the E Kit was requested and provided to the Facility at 6:45 P.M. and again at 7:35 P.M. to obtain morphine for Resident #1. During an interview on [DATE] at 2:50 P.M., the Hospice Chaplain said on [DATE], visited Resident #1 around 5:00 P.M., that the HCA was also there, and that he stayed with Resident 1# until 6:15 P.M. The Chaplain said he noticed Resident #1's respiratory rate vary throughout his visit and that Resident #1 respirations were elevated to close to ,d+[DATE] breaths per minute (normal rate range 12 to 16), said he informed nursing, and that was when nursing staff provided Resident #1 with oxygen. The Chaplain said he anointed Resident #1 and said he could tell, based on his experience, that Resident #1 was transitioning and actively dying. The Chaplain said Nursing staff (exact names unknown) told him that they were still waiting for Resident #1's morphine to be delivered from the pharmacy. The Chaplain said right after leaving the Facility, he immediately placed a call to Hospice Triage to inform them of Resident #1's significant change in condition. Review of Resident #1's Hospice Nurse Progress Note, dated [DATE], indicated she arrived at 6:20 P.M., and upon arrival Resident #1 was lying in bed with oxygen on at 2 liters (l) via nasal cannula. The Note indicated Resident #1's respiratory rate was 38 breaths per minute (normal rate range 12 to 16), pulse was 125 beats per minute (normal rate range ,d+[DATE]), blood pressure was ,d+[DATE] (normal range ,d+[DATE]), and his/her oxygen saturation was 68% (preferred range 90 -95% or higher with supplemental oxygen) on two liters of oxygen. The Note indicated that the facility staff was waiting for the pharmacy to deliver Resident #1's morphine. During an interview on [DATE] at 10:14 A. AM., the Hospice Nurse, said she was informed by the Hospice Triage Nurse that Resident #1 needed to be seen. The Hospice Nurse said the Hospice Triage Nurse reported to her that she needed to go see Resident #1 because he/she had been experiencing respiratory distress since the Facility first called in his/her change in condition at approximately 2:00 P.M., that day. The Hospice Nurse said she had arrived at the facility at 6:20 P.M., met with Resident #1 and his/her HCA in his/her room and said Resident #1 looked to be in a lot of distress. The Hospice Nurse said Resident #1 was in respiratory distress and was using his/her accessory (abdominal) muscles to breathe. The Hospice Nurse said that Resident #1's HCA told her she was glad she had arrived, because Resident #1 was in a lot of distress. The Hospice Nurse said she immediately went to locate Resident #1's nurse to see when the last time he/she had received any morphine to alleviate his/her respiratory distress. The Hospice Nurse said Nurse #1 told her that Resident #1 had not been administered any morphine yet because she was still waiting for the morphine to arrive from the pharmacy. The Hospice Nurse said she asked Nurse #1 if there was an Emergency (E) Kit in the Facility and that Nurse #1 said no, not on her cart. The Hospice Nurse then said she went to find the second nurse on the unit and asked if there was an E Kit in the Facility and that the nurse said yes, that it was located on the first floor. The Hospice Nurse said she went to the first floor to retrieve the E Kit. The Hospice Nurse said Nurse #4 called the Pharmacy to obtain the authorization code to open the E Kit to get the morphine for Resident #1. The Hospice Nurse said she administered morphine to Resident #1 at approximately 6:50 P.M The Hospice Nurse said no facility staff came into Resident #1's room to assess him/her or assist until after he/she was pronounced. The Hospice Nurse remained with Resident #1 (and his/her HCA) until he/she died at 7:38 P.M.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance from two staff members for bed mobility, the Facility failed to ensure Resident #1 received the appropriate level of staff assistance to prevent accidents resulting in injury, when on 01/12/22, Certified Nurse Aide (CNA) #4 provided morning care to Resident #1 without another staff member present to assist her. During care at some point Resident #1 yelled out in discomfort, CNA #4 continued to provide care alone, and did not report the incident to nursing. Resident #1 had pain and developed swelling to his/her left arm and required transfer to the Hospital Emergency Department where he/she was diagnosed with an acute spiral fracture (a type of broken bone that happens when a bone is twisted) of the distal ulnar diaphysis (bone in the forearm) with mild displacement and radial bowing (bending). Findings include: Review of the Facility's Policy titled, Accidents and Incidents, undated, indicated all accidents and incidents would be investigated and reported. Review of the Facility's Policy titled, Activities of Daily Living, undated, indicated that staff are required to provide necessary care and support to residents based on the comprehensive assessment of the resident's needs. Resident #1 was admitted to the Facility in November 2021, diagnosis included Diabetes, Dementia, and Weakness. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 11/18/21, indicated Resident #1 was cognitively impaired and required assistance of two staff members for bed mobility. Review of Resident #1's Certified Nurse Aide Care Card, undated, indicated that he/she required extensive assistance of two staff members for positioning. Review of Resident#1's Certified Nurse Aide (CNA) Flow Sheets, dated January 2022, indicated he/she required and CNAs documented he/she was provided with extensive assistance of two staff members for positioning. Review of Resident'#1's Nursing Progress Note, dated 01/12/22, indicated that Resident #1 experienced pain in his/her left arm and required transfer to the Hospital Emergency Department for further treatment and evaluation. Review of Resident #1's Hospital Discharge Summary, dated 01/12/22, indicated Resident #1 was diagnosed with an acute spiral fracture of the left arm distal ulnar diaphysis with mild displacement and radial bowing. Review of Resident #1's Nursing Progress Note, dated 01/13/22, indicated Resident #1's left arm was placed in a splint and his/her arm was swollen. Review of the Nurse Practitioner's Note, dated 01/14/22, indicated that Resident #1 experienced pain in his/her (left)arm. The Note indicated Resident #1 required a new intervention of scheduled over the counter acetaminophen (medication used to treat mild to moderate pain) 650 milligrams(mg) three times daily, for pain management. Review of Certified Nurse Aide (CNA) #4's written witness statement, dated 01/12/22, indicated that on 01/12/22, she was assigned to provide direct care to Resident #1 during the day and evening shifts (7:00 A.M. -11:00 P.M.). The Statement indicated that Resident #1 yelled out in discomfort during care and that she thought this was due to his/her diagnosis of Covid-19. The Statement indicated she did not report this to Resident #1's Nurse. The Statement indicated that later in the day Resident #1 motioned to his/her left arm and CNA #4 noticed swelling. During an interview on 02/03/22 at 12:40 P.M., Certified Nurse Aide (CNA) #4 said that on 01/12/22, she was assigned to care for Resident #1. CNA #4 said she was familiar with Resident #1's care needs and said Resident #1 required assistance from one or two staff members for bed mobility. CNA #4 said that on 1/12/22, she assisted Resident #1 with morning care, which included bed mobility, without the assistance of another staff member. CNA #4 said Resident #1 would hold onto the side rail during care. Review of Certified Nurse Aide Flow Sheets, dated 01/12/22, indicated that CNA #4 documented that two staff members assisted Resident #1 with bed mobility that day. Although CNA #4's documentation indicated two staff members assisted Resident #1 with bed mobility, this conflicted with CNA #4's Written Witness Statement and interview, where she said she provide care alone. CNA #4 said that when she went in to provide Resident #1 with incontinence care on 01/12/22 at approximately 3:00 P.M., Resident #1 was experiencing pain in his/her left arm and she noticed that it was now swollen. CNA #4 said that Resident #1 did not have any swelling during the day shift on 01/12/22. During an interview on 02/09/22 at 08:52 A.M., Nurse #6 said that she was the only Nurse assigned to Resident #1's Unit during the day shift (7:00 A.M. to 3:00 P.M.) on 01/12/2022 and she had one Certified Nurse Aide (CNA). Nurse #6 said she was not made aware that Resident #1 had pain during care and that if Resident #1 required a two person physical assist for bed mobility, said that the CNA should have asked her for assistance. During an interview on 02/03/22 at 12:18 P.M., the Unit Manager said that staff are required to follow the Certified Nurse Aide Care Card. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/14/22 at 6:45 P.M., indicated that Resident #1's Health Care Proxy/Agent (HCA) was interviewed and served as an interpreter as part of the investigation. The Report indicated that the HCA reported that Resident #1 said that he/she said banged his/her hand on his/her the side rail on his/her way to work. During an interview on 02/04/22 at 4:48 P.M., Resident #1's Health Care Agent (HCA) said she was made aware of the fracture by the Director of Nursing (DON). The HCA said that 01/13/22 Resident #1 told her that a woman twisted his/her arm. During an interview on 02/03/22 at 1:15 P.M., The Director of Nurses (DON) said that she completed the investigation into Resident #1's left arm fracture. The DON said it was an injury of unknown origin and said the Facility had been unable to determine how Resident #1's injury occurred.

Based on records reviewed, interviews, and observations, for two of three sampled residents, (Resident #2 and Resident #1), the Facility failed to ensure that they maintained residents safety, to prevent incidents resulting in injury. - On 7/21/21 Resident #2 (who resided on a secure unit), eloped from the unit through an alarmed door, went down two flights of stairs, and exited the facility through another alarmed door to an area in the rear of the facility, unbeknownst to staff. Resident #2 was found by the Police, he/she had an injury to his/her right arm, was transported to the Hospital Emergency Department for evaluation, and was admitted . - On 08/02/21, Resident #1, who had invoked Health Care Proxy and required an escort when going to outside appointments, was sent out to an appointment at the VA-Medical Center without an escort. Resident #1 eloped from the VA after his/her appointment and was not located until 08/04/21, when he/she was found in a hospital parking lot, was confused, was unaware of where he/she was, how he/she got there, or where he/she had been since 8/02/21, and was transferred to the Hospital Emergency Department for further evaluation. Findings include: 1. Review of the Facility's Policy titled Elopement and Wandering Residents, dated 8/01/19, indicated the following: - residents who exhibit wandering behavior and/or are at risk for elopement require adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. -residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -alarms are not a replacement for necessary supervision, staff are to be vigilant in responding to alarms in a timely manner. Resident #2 was admitted to the Facility in September 2019, diagnosis include dementia with behaviors present, diabetes mellitus, [CONDITION(S)], [CONDITION(S)], and hearing loss. Review of Resident #2's Health Care Proxy, dated 3/09/20, indicated his/her Health Care Agent was activated related to progressive advanced dementia. Review of Resident #2's Wandering Risk Scales, dated 3/15/21 and 6/15/21, indicated he/she was at high risk for wandering. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 7/01/21, indicated Resident #2 was cognitively impaired, required supervision with locomotion on and off the unit, and he/she had disorganized thinking and inattention daily. Review of Resident #2's Plan of Care related to Safety, which was updated with review of his/her 7/2021 MDS, indicated he/she walks with no purpose and is oblivious of his/her safety needs. Review of Resident #2's Certified Nurse Aide Care Card, undated, which was current per the Director of Nurses, indicated he/she required continual supervision with walking in his/her room and on the unit. Review of Resident #2's Certified Nurse Aide Flow Sheets, dated July 2021, indicated he/she required continual re-direction and supervision with walking both in his/her room and in the hallway. Review of Resident #2's Nursing Progress Note, dated 7/21/21, indicated the police department called the Facility at approximately 8:44 P.M. and asked if the Facility was missing any of their residents. The Note indicated, that the Police had found Resident #2 outside on the ground and he/she was being transported to the Hospital Emergency Department for evaluation. Review of Facility's Incident Report, dated 7/21/21, indicated Resident #2 was found outside of the Facility on the ground by police and transferred to the Hospital Emergency Department for evaluation. Review of Resident #2's Hospital Discharge Summary, dated 7/23/21, indicated he/she had a skin tear to his/her right arm and some of his/her blood laboratory work was abnormal. The Summary indicated the Facility would not re-admit Resident #2 until he/she had been off 1:1 supervision in the Hospital, for more than 24 hours. Review of Resident #2's Physician's Order, dated 7/23/21, indicated nursing to apply [MEDICATION(S)] Ointment 500 units per gram, to his/her right forearm topically daily (on the day shift) for wound care, and cover with dry protective dressing, until healed. Review of Resident #2's Wound Evaluation and Management Summary, dated 7/28/21, indicated he/she sustained a right arm skin tear measuring 9 centimeters (cm) by 3 cm by 0.1 cm. Review of Resident #2's Treatment Administration Record (TAR), dated August 2021, indicated that as of 8/04/21, two weeks after the injury occurred, treatment to his/her right arm skin tear, remained ongoing. Review of Video Only (no Audio) Surveillance footage provide by the Facility (who also shared that the video time stamp is approximately 50 minutes behind actual time) dated 7/21/21, indicated movements of Resident #2 on the unit and once off the unit, were as follows; - 6:57:31 P.M., Resident #2 is walking down the hallway toward his/her room which is located immediately next to the alarmed exit door at the end of the hall, he/she has a bag in his/her right hand with a coat and hat on. - 6:58:02 P.M., Resident #2 appears to be very close to the exit door (.20 second jump in camera time), the door does not open at this time, he/she turns toward the direction of his/her bedroom doorway. - 6:58:26 P.M., Certified Nurse Aide (CNA) #1 enters into the hallway from another room and has a bag in her right hand, CNA #1 looks to her left, down the hallway toward Resident #2, who is in the hallway near the door to his/her room and the exit door. CNA #2 disposes of bag in a room across the hall, and goes back to the room she was originally in. - 6:58:49 P.M., Resident #2 turns towards the exit door again and exits the unit. - 6:58:53 P.M., Resident #2 enters the stairwell. - 6:59:15/:23 P.M., CNA #1 heads toward the exit door (another .08 second skip in camera time). -6:59:43 P.M., CNA #1 looks to be entering the code to disarm the exit door. - 6:59:49 P.M., CNA #1 appears to look out through the in the door window, then turns around and goes back down the hallway. - Review of the video shows that CNA #1 does not open the exit door or step out through the exit door into the stairwell to check the stairwell or adjacent areas, in an attempt to determine reason for alarm. - 6:59:59 P.M., Resident #2 can be seen on camera going down the staircase. -7:00:06 P.M., Resident #2 tries to open the exit door in the stairwell, the door does not open, and he/she then turns toward the next flight of stairs, that leads to the ground floor. -7:00:06 P.M., Resident #2 can be seen turning around, tries to open the door again, this time it opens and he/she exits the Facility, to the outside. During an observation on 8/05/21 at 10:48 A.M., Surveyor #1, Surveyor #2, and Nurse # 5, tested the alarmed door on the third floor that was used by Resident #2 to exit the unit. Surveyor #2 depressed the handle to the door for approximately 4 seconds which activated the alarm and it sounded. Approximately 15 seconds later, a clicking sound was heard and the door lock disengaged, which then allows anyone to open the door and exit the unit. The alarm continued to sound until Nurse #5 entered the security code to reset the alarm and lock the door. During an observation on 8/05/21 at 10:53 A.M., Surveyor #1 and Surveyor #2 tested the alarmed door leading to the outside of the Facility that Resident #2 used to exit the facility. Surveyor #2 depressed the handle to the door for approximately 4 seconds which activated the alarm and it sounded. Approximately 15 seconds later, a clicking sound was heard and the door lock disengaged, which then allowed the surveyors to open the door and exit the facility. The alarm continued to sound until a maintenance worker used a remote device to turn off the alarm and reset the door. Surveyor #1 and Surveyor #2 observed that the exit door opened to the rear of the Facility, where there were parked cars and dumpster's. On 8/04/21 and 8/05/21, the Surveyors interviewed multiple staff members regarding exit door alarms, including the Nursing Supervisor, CNA #1, CNA #3, CNA #5, CNA #6, Nurse #2, Nurse #4, Nurse #5, and the Director of Nurses. Staff said that when responding to sounding alarms, staff should immediately stop what they are doing and go to the source of the alarm. Staff said if it is an alarmed door and there appears to be no one in sight, they must investigate why that alarm was triggered. Staff said they would open the door, and would go out beyond the door to see who may have triggered the alarm. Staff said that they would not stop looking for why the alarm sounded until they knew the reason. Staff said if no one was found in the area to account for the alarm, they would complete a complete head count of all residents to ensure all were accounted for. The Nursing Supervisor, Assistant Director of Nurses, Nurse #1, Nurse #2, Nurse #4, CNA #2, CNA #3, CNA #5, and CNA #6 said that Resident #2 often wanders the hallway, that Resident #2 was known to put his/her hat, jacket, and carry a bag or purse, while walking up and down the hallway. Staff said Resident #2 would say he/she was going to the store for some gum or to catch the bus or train, and that this was his/her typical behavior. During an interview on 8/04/21, at 9:30 A.M., the Staff Development Coordinator said she was new and had no idea if education on alarms was done, and could not locate any documentation of the Facility ever in-servicing staff on responding to door alarms and its importance. During an interview on 8/10/21 at 3:39 P.M., Certified Nurse Aide (CNA) #1, said that Resident #2 will frequently put his/her jacket and hat on, get his/her bag or purse and wander up and down the hallway. CNA #1 said Resident #2 will tell me he/she is going to the store or maybe catching a train to the store. CNA #1 said she was assigned to Resident #2's unit the day he/she eloped from the Facility. CNA #1 said she was providing care for another resident, had come out into the hallway, saw another resident with a dinner tray, took the tray to put it away for the resident, and said she could not be certain at what point she heard the exit door alarm sound. CNA #1 said she put the dinner tray down, and headed to the exit door to reset the alarm. CNA #1 said she looked out of the window in the door, did not see anyone, and continued on with her assignment. During an interview on 8/05/21 at 2:30 P.M., the Director of Nurses (DON) said it is her expectation that staff members respond to all alarms and are expected to investigate how and why the alarm was triggered. The DON said after Resident #2 eloped from the facility on 7/21/21, his/her room was changed to a room closer to the nurse's station, for better observation. However, as of 8/05/21, Resident #2 was still residing in the same room at the end of the hallway, adjacent to the exit door, which he/she had used to elope from. 2. Review of the Facility Policy titled Resident Appointment Schedule, dated 08/01/2017 as last revised 07/26/2021, indicated the following; In an effort to minimize concerns related to residents appointments/transportation, the facility should review all appointments on weekly basis minimally, to ensure a proactive approach is being taken for future appointments and that transportation has been allocated/secured as well as resident escort if necessary. Resident #1 was admitted to the Facility in May 2018, diagnoses included Dementia, [CONDITION(S)], Wernicke's [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and history of Alcohol dependence. Review of Resident #1's Physician orders indicated his/her Health Care Proxy was activated, dated 06/01/18, that Resident #1 was incapable of making informed decisions due to [CONDITION(S)]. Review of Resident #1's Plan of Care related to Communication, reviewed with his/her most recent MDS, dated [DATE], indicated that he/she has impaired cognition due to dementia and history of Alcohol abuse, that he/she has a communication problem due to [CONDITION(S)] and Dementia, and had an impaired ability to make self-understood and to understand others. Resident #1's Plan of Care interventions included that he/she required cueing and task segmentation, and for staff to anticipate and meet needs. Review of Resident #1's Plan of Care related to Dementia, dated as revised 04/15/21, indicated that he/she had impaired cognitive abilities and to monitor for changes in cognitive function, decision making ability and general awareness. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/02/21, indicated Resident #1 was sent to out an outside appointment, signed into his/her appointment at VA and subsequently went missing. Review of the Hospital Emergency Department Note, dated 08/04/21, indicated Resident #1 was found wandering the parking lot by security. The Summary indicated Resident #1 said he/she did not know where he/she was, did not know why he/she was there, or how he/she got there. The Summary indicated Resident #1 exhibited signs and symptoms of an acute change in mental status. The Summary indicated Resident #1 was on a missing persons list from a VA rehab. During an interview on 08/04/21 at 11:00 A.M., the Health Care Proxy (HCP) said before the pandemic, he used to accompany Resident #1 to all his/her appointments outside the Facility, however, when he could no longer go with Resident #1, the Facility sent him/her with an escort to all outside appointments. The HCP said he did not understand why the Facility sent Resident #1 to an outside appointment without an escort on 08/02/21. During an interview on 08/09/21 at 11:49 A.M., Nurse #6 said that Resident #1 was on her assignment on 08/02/21. Nurse #6 said she was not aware that Resident #1 had an appointment that day until VA transportation came to pick up him/her up at 8:30 A.M. for an Optometrist appointment. Nurse #6 said that she sent Resident #1 out for the appointment without an escort and said this was not the first time she had done that. Nurse #6 said there were times when she sent Resident #1 with an escort and other times without an escort. During an interview on 08/04/21 at 11:30 A.M., Nurse #1 said that Resident #1 was not on her assignment the day of the incident. Nurse #1 said Resident #1 had been her assignment multiple times and said she never sent Resident #1 without escort to outside appointments. Nurse #1 said she was surprised Resident #1 was sent out without an escort. During an interview on 08/05/21 at 12:00 P.M., the Assistant Director of Nurses (ADON) said to the best of her knowledge Resident #1 always required an escort for outside appointments. The ADON said she was not sure what happened on 08/02/21 or if staff were even aware that Resident #1 had an appointment that day. During an interview on 08/05/21 at 2:00 P.M. with the Director of Nursing (DON) said they were unable to determine why Resident #1 was sent out to an appointment without an escort.

Based on record review, staff interview, and facility policy review, the facility failed to maintain acceptable parameters of nutritional status for two Residents (#14, #97). Specifically the facility failed to: 1) Identify and assess a significant weight gain for one Resident (#14); 2)Offer sufficient fluids and follow their hydration protocol policy to maintain proper hydration which resulted in Resident #97 becoming dehydrated, falling and hitting his/her head requiring 6 staples to the back of the his/her head. Further when Resident #97 returned from the hospital the facility failed to ensure Resident #97 received the 1 to 2 liters of fluid as ordered by the Physician. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, undated, indicated the following: -Any weight change of 5% or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the Dietitian and Physician. -The Dietitian will review the weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight changer had been meet. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant. b. 3 months - 7.5% weight loss is significant. c. 6 months - 10% weight loss is significant. -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made. -The physician and multidisciplinary team will identify conditions and medications that may be causing weight loss or increasing risk of weight loss. -Care planning for weight loss or impaired nutrition will be multidisciplinary effort and will include the Physician, nursing staff, Dietitian, Pharmacist and the resident or resident legal surrogate. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences b. Nutritional and hydration needs of the resident. c. Functional factors that may inhibit independent eating. d. Environmental factors that may inhibit participation in meals. e. Chewing and swallowing abnormalities. f. Medications that may interfere with appetite, chewing or digestion. g. The use of supplementation and/or feeding tubes. h. End of life decisions and advanced directives. -The Dietitian will discuss undesired weight gain with the resident and/or family. 1.) For Resident #14, the facility failed to implement an intervention for a significant weight gain. Resident #14 was admitted to the facility in December 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #14's most recent Minimum Data Set (MDS) dated [DATE], indicated that he/she was unable to complete the Brief Interview for Mental Status and staff assessed him/her to have severe cognitive impairment. The MDS also indicated that Resident #14 required extensive assistance from staff for all other daily tasks. Review of Resident #14's weights indicated the following: 12/1/20: 138 pounds 1/5/21: 133.5 pounds 2/5/21: 134.2 pounds 3/2/21: 136.6 pounds 4/1/21: 134.7 pounds 5/2/21: 145.7 pounds (a 8% gain in one month) 6/3/21: 146.4 pounds Review of Resident #14's nursing notes failed to indicate a note regarding the weight gain recorded on 5/1/21 and 6/3/21. The nursing notes also failed to indicate that the Nurse Practitioner and Dietitian were notified of the weight gain. Review of Resident #14's medical record indicated that his/her nutrition care plan had not been revised since 9/20/19, and that the Dietitian had not assessed or seen Resident #63 since 3/12/21. Review of the medical record and document titled, [NAME] Nutritional Assessment Comprehensive, dated 3/12/21, indicated the following: -Resident #14's ideal weight is 105 pounds -Nutritional intervention: Continue with puree thin and bedtime snack. Continue with one Glucerna (a diabetic supplement) - monitor intakes and weights. Continue with resident feeding. During an interview on 6/11/21 at 8:24 A.M., Nurse #5 said that if a significant weight gain is noticed after weighing a resident, the nurses must report that weight gain to the nurse supervisor and dietitian. Nurse #5 said that the nurses don't automatically get a re-weight with a significant weight change and that the Dietitian will let the nurses know if a re-weight is needed. Nurse #5 said that if a resident had a significant weight gain, the intervention would be to weigh the resident more and monitor closely. During an interview on 6/10/21, at 1:27 P.M., the Dietitian said that she works at the building three days a week. The Dietitian said that the nursing staff is generally good about getting weights but that she has to request re-weighs at times. The Dietitian said that she reviews weights of all the residents once a week. She said that the facility has not been having a weekly risk meeting to discuss weight loss/gain in the building but said the team touches base all the time. The Dietitian said that she completes assessments on every resident at least quarterly and if a resident were to have a significant change in weight within that time frame, she would assess the resident and would write a note, not complete a full assessment. The Dietitian said that the computer program that the facility uses generates a weight report for her and would indicate any significant weight gains or losses. The Dietitian said that she would expect nurses to re-weigh a resident with a significant weight loss or gain within 48 hours. She also said that her expectation is that nursing will notify her immediately if any resident has a significant change in weight. The Dietitian said that she had not been notified regarding Resident #14's significant weight gain. She also said that she had not noticed it on the weight report that she reads because when reading the report she typically just focuses on weight loss. She said that Resident #14 may be getting ensure (a dietary supplement) with all of his/her medication. The Dietitian said that this would be beyond her recommended of one supplement a day and could be an explanation for the weight gain. The Dietitian further said that the Administrator had recently noticed that there had been quite a few weight gains in the facility and that she was now aware she needed to also focus on weight gains, not just weight losses. 2.) Review of the facility policy titled Hydration Protocol, dated 3/12/13, indicated the following: *Policy- Resident will have access to adequate fluids for hydration; to identify residents at risk for dehydration or needing acute re-hydration and that appropriate interventions are initiated timely. *Purpose:-To promote adequate hydration and to assure residents receive adequate fluid intake according to their individual needs. *Nursing Responsibility- Shift designated by the DON, will be responsible to total the intake and output. *If the resident has not met their 24 hour fluid requirements within 3 consecutive days the following actions should be taken: 1. Assure the dehydration checklist is being completed every shift for those residents on intake and output. and does not reflect any signs or symptoms of dehydration, If no signs or symptoms of dehydration are present, you do not need to notify the Physician and or Nurse Practitioner. This checklist may be placed in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. If the resident does not exhibit signs and symptoms of dehydration, the physician and/or Nurse Practitioner must be notified for further orders. 3. If the resident has not met their 24 hour fluid requirement within 6 consecutive days, complete a hydration evaluation and notify the Physician/Nurse Practitioner regardless the resident does or does not have signs and symptoms of dehydration. Continue monitoring the residents intake and output, unless otherwise specified. Resident #97 was admitted in December 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #97's most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #97 has short and long term memory problems and his/her cognitive skills for daily decision making were severely impaired. The MDS further indicated that Resident #97 required limited assistance with bed mobility, transfers, walking, eating, toilet use and personal hygiene, required extensive assistance with dressing and physical help in part of the bathing activity. Review of Resident #97's lab values, dated 4/5/21, indicated a high Blood Urea [MEDICATION(S)] (a lab test used to determine kidney function) lab value of 31. Normal Range is 10-24, a high level can indicate dehydration. Review of the Progress notes for April 2021 indicated the following: *4/13/21-Physician's note-New Evaluation-Patient's charts, tests, labs. meds and history reviewed. Patient recently had lab work, urinalysis and [MEDICATION(S)] (a medication used to treat seizures and [CONDITION(S)]) level to evaluate functional decline. Labs and exam noncontributory. *4/13/21-Resident was sweating , looked to be having abdominal pain, Doctor called and gave order to send to the emergency department. *4/14/21-Nursing note -Resident back from the hospital, work up is negative, doctor called, no new orders,. Resident barely ate his/her meals, consumed 20% of breakfast and lunch. *4/14/21-Dietitian note-Resident returned from the emergency room around 1:00 A.M., intake documented as poor, consuming 20%-30%, Resident has been given ensure by nursing. Recommendation: reweigh, fortified foods, ensure daily, monitor/document intakes, tolerance and weights. *4/15/21-Nursing note-Poor appetite on feeding meals. *4/16/21-Nursing note-Poor appetite on his/her feeding meals. *4/17/21-Nursing note-Poor appetite, poor fluid intake. only drank one can of Ensure (a nutritional supplement). *4/19/21-Dietitian note- Resident is documented as being fed by staff and having a poor appetite. Some days it appears he/she drinks all of Ensure and other days only 1 can. Resident had a large weight loss. *4/23/21-Dietitian note- Resident is documented as being fed by staff and having a poor appetite. Dietitian observed staff feeding resident ensure as he/she is walking. He/she accepts it but has a hard time sitting down for a meal. Some days it appears that he/she drinks all of Ensure and some days only 1 can. *4/23/21-Nursing note-Resident is 1:1 supervision by staff and provided hands on assist as needed for safety, poor appetite, drank 1 can of Ensure this shift. *4/25/21-Nursing note-Fed by staff, fair appetite. *4/26/21-Nursing note- Assume took breakfast meals 50%, drink Ensure 200 ml, lunch meal 80% drink ensure 240 ml, fed by staff, fair appetite. Review of Resident #97's Progress notes from 4/15/21-4/26/21 failed to indicate that the Physician was notified regarding Resident #97's poor appetite and fluid intake. Review of Resident #97's Lab results failed to indicate any further lab work was completed at the facility since 4/5/21. Review of Resident #97's Nurse's note dated 4/27/21, indicated that Resident #97 fell in the hallway, hit his/her head, and was sent to emergency room . Review of Resident #97's Nurse's note dated 5/1/21, indicated that Resident #97 returned from the hospital with 6 staples to right back of head. Review of Resident #97's discharge summary from the hospital dated 5/1/21- indicated the following: *The patient has decreased po (by mouth) intake due to dementia which likely led to dehydration. Please make sure the patient takes 1-2 liters of fluid daily. *His/her fall was most likely triggered by dehydration as the patient had an acute kidney injury and a systolic blood pressure in the 80's on admission. Orthostasis and [CONDITION(S)] (a decrease in blood pressure that happens after a person stands up) resolved after intravenous fluids. Review of Resident #97's dehydration risk screen dated 5/1/21, indicated that Resident #97 scored an 11 which indicated a high risk for dehydration. Review of Resident #97's Doctor's orders indicated an order dated 5/1/21 :Please make sure the Resident takes 1-2 liters (1000 milliliters(ml)-2000 ml)of fluid daily, every shift for dehydration. Review of Resident #97's May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *5/2/21-500 ml *5/3/21-700 ml *5/4/21-840 ml *5/6/21-950 ml *5/7/21-840 ml *5/9/21-240 ml *5/10/21-820 ml *5/17/21-837 ml *5/18/21-930 ml *5/23/21-960 ml *5/24/21-837 ml *5/31/21-960 ml On 6/15/21, the surveyor reviewed Resident #97's June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *6/6/21-900 ml *6/7/21-900 ml *6/8/21-920 ml *6/14/21-900 ml During an interview on 6/16/21 at 1:15 P.M., Nurse #14 said he looks at Resident #97's meal tray and adds up those fluids as well as the Ensure supplement that he gives Resident #97 and then he documents the total for his shift on the MAR. Nurse #14 said that there is no formal assessment or evaluation that he completes to monitor for sign and symptoms of dehydration, and he does not add up the total 24 hour intake, and was not aware that Resident #97 was not meeting his/her ordered fluid intake. During an interview on 6/16/21, at 12:50 P.M., the Director of Nursing (DON) said that Resident #97 is not on output tracking, but is now on fluid intake tracking since his/her hospitalization for the fall. The DON said that the nurse's document Resident #97's fluid intake on the MAR . When asked whose responsibility it is to total the intake to make sure that Resident #97 receives the 1-2 liters of ordered fluids, the DON said that it is the responsibility of the 11-7 nurse to add up the total. When shown the MAR from May and June with the totals below the ordered 1 liter or 1000 ml, the DON said that it didn't look as though 11-7 was monitoring and adding up the fluid intake for the 24 hours. The DON said that there is not a formal assessment for hydration that the nurse's are filling out during their shift to monitor Resident #97 for signs and symptoms of dehydration. The DON further said that the fall on 4/27/21 was caused by low blood pressure from Resident #97 being dehydrated.

Based on observation, record review, interview and facility policy review, the facility failed to ensure that 1 Resident, (#97) out of a total of 41 sampled residents received appropriate supervision to avoid a fall resulting in six (6) staples to the back of his/her head, and 2) the facility failed to provide adequate supervision with ambulation for Resident #97 after the fall with major injury. Findings include: Review of facility policy titled Fall Prevention, undated, indicated the following: *The facility will implement interventions to minimize and/or eliminate contributing factors for falls on residents at risk. *The facility will provide education on fall prevention to caregivers, residents, and family. *In the event a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. If a resident falls, the following measures will be instituted: Implement interventions as appropriate to prevent reoccurrence. Resident #97 was admitted in December 2019 with diagnoses including severe [CONDITION(S)] with psychotic features, [CONDITION(S)], [CONDITION(S)] disorder and post traumatic stress disorder. Review of Resident #97 Minimum Data Set (MDS) dated [DATE], indicated that Resident #97 has short and long term memory problems and his/her cognitive skills for daily decision making were severely impaired. The MDS further indicated that Resident #97 required limited assistance with bed mobility, transfers, walking, eating, toilet use and personal hygiene, required extensive assistance with dressing and physical help in part of the bathing activity. Review of a facility document titled Fall Risk assessment dated [DATE], and 4/29/21, indicated that Resident #97 was a moderate risk for falls. Review of Resident #97's activities of daily living care plan with a revision date of 3/11/21, indicated the following intervention: *I need you to continually supervise me with ambulation and assist me as needed. Review of Resident #97's fall care plan with a target date of 8/18/21, indicated the following intervention: *When I walk I need assist of one staff. Review of Resident #97's Nurse's note dated 4/27/21, indicated that Resident #97 fell in the hallway, hit his/her head, and was sent to the emergency room . Review of the facility form titled Incident Report Form with a date of 4/28/21, indicated the following: *Internal Investigation Narrative: Resident observed lying on the floor by the nursing station, sustained posterior head laceration. Resident unable to explain how the fall happened due to confusion. Order given by Nurse Practitioner to send Resident to emergency room . *Incident description by nursing- I was on the desktop signing medication when I heard a sound, I ran and saw the resident on the floor. He/she hit his/her head on the wall with a small cut 0.2 X 0.2 centimeters and a little red bruise on the right shoulder. *Witnesses-No witnesses. Review of Resident #97's nurse's note dated 5/1/21, indicated that Resident #97 returned from the hospital with 6 staples to the right back of head. On 6/14/21, at 12:40 P.M. to 12:50 P.M., the surveyor observed Resident #97 walking the hall on the China Garden unit unsupervised. On 6/15/21, at 9:40 A.M. to 9:50 A.M., the surveyor observed Resident #97 walking the hall on the China Garden unit unsupervised. On 6/16/21, from 8:43 A.M., to 8:53 A.M., the surveyor observed Resident #97 walking the China Garden unit and in the dining room unsupervised. During an interview on 6/14/21, at 12:41 P.M., Nurse #8 said that Resident #97 should be supervised during ambulation. During an interview on 6/16/21, at 8:21 A.M., Nurse #14 said that Resident #97 should be supervised during ambulation. During an interview on 6/16/21, at 12:50 P.M., the surveyor notified the Director of Nursing (DON) of her observations of Resident #97 ambulating independently on the unit. The DON said that Resident #97 should always be supervised and always have someone with him/her at arms length while he/she is ambulating. The DON also said that Nurse #7 was at the computer and his/her back was to Resident #97 when he/she fell on [DATE].

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 2 Residents (#29 and #95) out of a total sample of 41 residents. Findings include: 1.) Resident #29 was admitted to the facility in October 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #29's most recent Minimum Data Set (MDS) dated [DATE], indicated that he/she was unable to complete the Brief Interview for Mental Status and staff assessed him/her to have severe cognitive impairment. The MDS also indicated that Resident #29 is dependent on staff for all mobility and self-care tasks. On 6/9/21, at 8:30 A.M., Resident #29 was observed lying in bed with both hands in a closed fist position. Resident #29 was unable to follow the verbal commands provided by the surveyor to open his/her hands. Review of Resident #29's medical record indicated the following: -An Occupational Therapy (OT) evaluation dated 1/26/21, which indicated Resident #29 had full range of motion of his/her right hand. -An OT discharge summary dated 2/25/21, which indicated that upon discharge from therapy, staff was able to passively move Resident #29's right fingers to full functional range. -An OT eval dated 6/11/21, which indicated that the reason for referral was a right hand contracture. The OT eval indicated that Resident #29 could move all joints in his/her hand and fingers. The OT eval also indicated that the joints in Resident #29's left hand could only open partial range of motion. -The list of Resident #29's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/10/21, at 10:55 A.M. with Resident #29 present, Certified Nursing Assistant (CNA) #2 attempted to open Resident #29's left hand from the closed fist position. CNA #2 said that Resident #29 has had a left-hand contracture for a while and had been treated by therapy in the past. CNA #2 said that therapy had provided Resident #29 with a hand carrot (hand orthotic used to keep hand open) and Resident #29 used to hold it every day and now is unable to. CNA #2 said that because Resident #29's left hand has closed tighter, it is not only difficult for Resident #29 to hold the carrot, but that CNA #2 believes it causes a lot of pain and that the Resident suffers when it is in and that she believes wearing the splint causes Resident #29 pain. When asked how she would know the Resident is in pain, CNA #2 said that Resident #29 will pull his/her hands back and facial grimace. CNA #2 said that this is a new reaction. CNA #2 said that she is unable to open Resident #29's left hand to complete range of motion exercises and that Resident #29's left hand contracture had definitely gotten worse. CNA #2 then attempted to open Resident #29's right hand from the closed fist position and was unable to. CNA #2 said this is a new contracture because Resident #29 had always been able to open his/her right hand fully. During an interview on 6/10/21 at 11:07 A.M., Nurse #4 said that Resident #29 has had a left-hand contracture and was given a hand carrot by the therapy department. The surveyor and Nurse #4 then went into Resident #29's room and Nurse #4 attempted to place the carrot in Resident #29's hand and was unable to. Nurse #4 said she was unable to place the carrot in Resident #29's hand because his/her hand was closed too tightly, and she was unable to open the Resident's hand. Nurse #4 said that the left-hand contracture was worse. Nurse #4 then attempted to open Resident #29's right hand from the closed fist position and was unable to. Nurse #4 said that this is a new contracture. During an interview on 6/15/21 at 9:27 A.M., the Director of Rehabilitation (DOR) said that she does not do formal rounds in the building to screen for possible new contractures. The DOR said that nursing will send a referral for a change in range of motion to therapy and that therapy will then complete an evaluation. The DOR said that she had not received a referral for Resident #29's change in range of motion. The DOR said that she completed the OT eval for Resident #29 on 6/11/21 and that Resident #29 had a new right-hand contracture. 2.) Resident #95 was admitted in October 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #95's most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #95 was rarely/never understood and had short and long term memory problems. Further review of the MDS indicated that Resident #95 did not ambulate and was totally dependent with all activities of daily living. On 6/10/21, at 9:10 A.M., the surveyor observed Resident #95 in bed and Resident #95's left hand was in a flexed (fist) position. On 6/14/21, at 2:15 P.M., Nurse #8 accompanied the surveyor into Resident #95's room and observed Resident' 95's left hand. Resident #8's hand was in a fist position and Nurse #8 attempted to assist Resident #95 to open his/her left hand. Resident #95 was able to open his/her hand to only 25% of the possible range of motion required for a fully open hand. Nurse #8 said that Resident #95 used to be able to open his/her hand fully, but has had a decline and his/her left hand has gotten worse and is unable to open. Review of Resident #95's clinical record failed to indicate that Resident #95 had any neurological conditions that would contribute to the development of a contracture. Review of Resident #95's Occupational Therapy plan of care dated 1/5/21 did not indicate any impairment with range of motion to Resident #95's left hand. Review of Resident #95's Doctor's orders on 6/10/21, failed to include orders for any devices for Resident #95's left hand. During an interview on 6/15/21, at 9:45 A.M., Occupational Therapist (OT)#1 said that she treated Resident #95 in January 2021. OT #1 reviewed the evaluation completed on 1/5/21, and said she did not recall an impairment to the left hand. She said that if a contracture was now present in Resident #95's left hand that it would be new. During an interview on 6/15/21 at 9:27 A.M., and at 10:00 A.M., the Director of Rehabilitation (DOR) said that she does not do formal rounds in the building to screen for possible new contractures. The DOR said that nursing will send a referral for a change in range of motion to therapy and that therapy will then complete an evaluation. The DOR said that she had not received a referral for Resident #95's change in range of motion. The DOR said that she just received a referral form from nursing for Resident #95's left hand contracture on 6/14/21, and had completed an OT evaluation on 6/14/21. She further said that Resident #95's left hand is now contracted.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted with surgical wounds to his/her right groin and right heel, the Facility failed to thoroughly assess and document Resident #1's right groin and right heel surgical wounds and failed to ensure he/she attended follow up appointments with the Vascular Surgeon. On 09/14/20, three months after his/her surgery, Resident #1 was transferred to the Hospital Emergency Department and was found to have sutures still in place to his/her right heel surgical wound that required a painful and extensive procedure to remove the sutures. Findings include: Review of the Facility Policy, titled, Physician Services, undated, indicated Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. Consultative services shall be made available from community-based consultants or from a local hospital or medical center. Review of the Facility Policy, titled, Nursing Care of the Resident with Diabetes Mellitus, undated, indicated complications associated with diabetes included foot complications such as [MEDICAL CONDITION] (nerve damage), dry skin, calluses, poor circulation, and ulcers, and documentation would include assessment of the feet including hygiene, temperature, color, circulation, any abrasions, sores, or injuries, corns or calluses, and the condition of the toes and toenails. Review of the Facility Policy, titled, Wound Care, dated 2017, indicated staff would document in the resident's medical record all assessment data including wound size, wound bed color, any drainage, or other assessment obtained when inspecting the wound. Resident #1 was admitted to the Facility in June 2020 with [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Discharge Summary, dated 06/22/20, indicated Resident #1 was discharged to the Facility with surgical wounds to his/her right groin and right foot. The Hospital Discharge Summary indicated Resident #1 was scheduled for a follow up appointment with the Vascular Surgeon on 07/17/20. Review of Resident #1's medical record indicated there was no documentation to support that he/she attended the vascular surgeon follow up appointment on 07/17/20. Review of the Facility's appointment book indicated there was no documentation to support that Resident #1 was scheduled for a follow up appointment with the vascular surgeon on 07/17/20. Review of Resident #1's Admission Nursing Assessment, dated 6/22/20, indicated Resident #1 had a surgical incision on his/her right groin and a surgical wound on his/her right heel. Further review of Resident #1's medical record indicated there was no documentation to support that a thorough assessment of Resident #1's right groin and right heel wounds including measurements and presence of sutures in his/her right heel was completed. Review of the Progress Note, dated 08/05/20, indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation and was admitted for psychiatric care. Review of the Hospital's Consultation Note, dated 08/14/20, indicated Resident #1 was assessed as having a surgical wound on his/her right heel measuring 3 centimeters (cm) by 2.5 cm with 18 intact sutures. Review of the Hospital Discharge Summary, dated 08/14/20, indicated Resident #1 would require follow up for suture removal to the wound on his/her right foot. During interview on 01/14/21 at 12:15 P.M., Nurse Supervisor #1 said appointments were documented in the appointment book and kept at the nurses' station and said individual appointments were not written as physicians' orders. Nurse Supervisor #1 said she did attempt to book a follow up appointment for Resident #1 after he/she was readmitted to the facility on [DATE], however she said she did not document her attempts to obtain a follow up appointment in Resident #1's medical record. Review of Resident #1's medical record indicated there was no documentation to support that a follow up appointment was made for Resident #1's suture removal to his/her right foot when he/she was readmitted to the facility on [DATE]. Further review of Resident #1's medical record indicated there was no documentation to support that a thorough assessment of Resident #1's right groin and right heel wounds including measurements was completed upon readmission to the facility on [DATE]. Review of the Facility's appointment book indicated there was no documentation to support that Resident #1 was scheduled for a follow up appointment with the Vascular Surgeon after being readmitted to the facility on [DATE]. Review of Resident #1's Progress Note, dated 09/14/20, indicated Resident #1 fell and was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Admission History and Physical, dated 09/14/20, indicated Resident #1's right foot was assessed with [REDACTED]. The Physical indicated Resident #1 was prescribed [MEDICATION NAME] (antibiotic) Intravenous (IV) 600 milligrams (mg) for [MEDICAL CONDITION] (skin infection) and osteo[DIAGNOSES REDACTED] (bone infection). Review of Resident #1's Hospital Podiatry Consult Note, dated 09/16/20, indicated he/she was found to have sutures on his/her right heel still in place from the vascular surgery performed in June 2020. The Note indicated Resident #1's sutures were found to be deep and buried under scar tissue, eschar, and scabs extending from the bottom of the foot to the heel. The Note indicated a [MEDICATION NAME] (numbing medication) injection was not recommended due to scar tissue and that it would cause more pain for Resident #1. The Note indicated Resident #1 became agitated, was threatening and kicking staff during the suture removal and did not allow the Physician to remove the last suture. The Note indicated he/she was administered [MEDICATION NAME] (antipsychotic medication); however, the Physician was still unable to remove the last suture on that day. During interview on 01/13/21 at 11:30 A.M., the Director of Nurses (DON) said the Facility's procedure for tracking residents' physician appointments outside of the Facility was for staff to write appointments in the appointment book at the nurses' station. The DON said appointments were not written as physician's orders in the medical record. The DON said the process for tracking residents' appointments was a weak point for the Facility and said Resident #1 did not have an appointment scheduled in the appointment book or attend a vascular appointment on 7/17/20 or any other day.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being paranoid and delusional, which increased over a period of several months, the Facility failed to ensure he/she was provided with adequate supervision and safety interventions to prevent an incident with an injury. On 12/20/19, Resident #1, attempted suicide by cutting his/her left wrist, he/she was transferred to the Hospital Emergency Department for evaluation, required four sutures to close his/her wounds and was admitted for psychiatric evaluation. Findings include: The Facility's Investigation, dated 12/21/19, indicated that on 12/20/19, Resident #1 used a metal blade to cut his/her left wrist twice, each wound measured approximately one centimeter long. The Investigation indicated psychiatric services assessed Resident #1 and he/she was transferred to the hospital due to paranoid delusions. The Hospital Report, dated 01/03/20, indicated Resident #1 was admitted on [DATE] after he/she cut his/her left with with a razor in an apparent suicide attempt and required 4 sutures to his/her left wrist. The Report indicated per collateral information obtained by the psychiatric team, Resident #1's delusions were apparently chronic and have been occurring for one to two years. Resident #1 was admitted to the Facility in (MONTH) 2019, [DIAGNOSES REDACTED]. The Psychiatric Nurse Practitioner Note, dated 9/12/19, indicated that Resident #1 presented as confused, believes that someone is attacking him/her at night and that someone is trying to strangle him/her. The Note indicated Resident #1 was diagnosed with [REDACTED]. The Psychiatric Nurse Practitioner Note, dated 10/03/19, indicated that Resident #1 was anxious, paranoid, and delusional, and that Resident #1 thinks that someone is killing him/her but he/she cannot see the persons face. The Note indicated that Resident #1 said he/she has difficulty breathing sometimes when he/she is afraid. The Note indicated recommendations to start Resident #1 on [MEDICATION NAME] (antipsychotic medication) 25 milligrams (mg) twice daily for anxiety and [MEDICAL CONDITION]. The Psychiatric Nurse Practitioner Note, dated 11/26/19, indicated Resident #1 was referred for delusional thoughts about getting the death penalty, that Resident #1 reports a man comes out the speaker on the ceiling and wants to kill him/her. The Note indicated Resident #1 is increasingly delusional and paranoid, believes a badman is going to appear out of the speakers and kill him/her. However, review of Resident #1's medical record indicated that despite Resident #1 needing to be assessed and followed by psychiatric services, 9/2019 through 11/2019, after he/she began exhibiting paranoid and delusional behaviors, required the addition of an antipsychotic medication with dosage adjustments, the Facility failed to develop and/or implement interventions to maintain Resident #1's safety as well as his/her mental and psychosocial well-being. During an interview on 1/7/20 at 11:45 [NAME]M., Certified Nurse Aide (CNA) #1 said that she provided morning personal care to Resident #1 on 12/20/19. CNA #1 said that shortly after assisting Resident #1 with care, he/she showed her his/her wrist had cuts and he/she was bleeding and she notified the nurse. During an interview on 1/7/20 at 12:20 [NAME]M., Nurse #2 said that upon assessing Resident #1's injuries, he/she said words to the effect of, He's trying to get me, they're coming. During an interview on 1/7/20 at 2:30 P.M., Psychiatric Nurse Practitioner (NP) #1 and NP #2 said they provided medication management services to Resident #1. NP #2 said that in the past, it had been difficult to assess and treat Resident #1, given the language barrier and his/her cognitive loss. During an interview on 1/7/20 at 1:15 P.M., The Director of Nurses said that that Resident #1 did not have any non-pharmaceutical interventions on his/her Plan of Care to address his/her [DIAGNOSES REDACTED].>

Based on observations, records reviewed, and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision, when: -On 05/09/19, Resident #1, a severely cognitively impaired resident, at risk for elopement, eloped from his/her locked unit, and was found on the ground outside of the Facility by staff. Resident #3 was transferred to the hospital where he/she was diagnosed with [REDACTED]. -On 06/06/19, Resident #2, a mildly cognitively impaired resident, at risk for elopement, removed his/her wander guard and eloped from his/her locked unit, and was found walking down a sidewalk by a staff member. Resident #2 was transferred to the hospital where he/she was diagnosed with [REDACTED]. Findings include: The Facility's Policy, dated (YEAR), indicated that if an employee observes a resident leaving the premises, he/she should attempt to redirect the resident in a courteous manner and get help from another staff member, if necessary. The Policy indicated the whereabouts of each resident be monitored on a regular basis and the residents be provided care in a secure environment. 1. Resident #1's Face Sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR); [DIAGNOSES REDACTED]. Resident #1's Health Care Proxy was invoked in (MONTH) 2019 due to Resident #1's severe dementia. Resident #1's Minimum Data Set (MDS) Assessment, dated 04/09/19, indicated he/she had severe cognitive impairment, had difficulty hearing, required supervision for ambulation, and his/her preferred language was Cantonese. Resident #1's Fall Prevention Care Plan, dated 04/22/19, indicated he/she was at risk for falling due to an unsteady gait and balance, was prescribed [MEDICATION NAME], and had a history of [REDACTED]. Resident #1's Elopement Risk Assessment, dated 04/08/19, indicated Resident #1 was at risk for elopement from the Facility. Resident #1's Elopement Care Plan, dated 05/10/19, indicated it was unsafe for him/her to leave the Facility but he/she may attempt to do so. The Care Plan indicated Resident #1 required staff to monitor his/her whereabouts frequently and re-direct him/her away from his/her locked unit doors. Resident #1's Nursing Progress Note, dated 05/09/19, indicated staff members found him/her on the ground outside the Facility with abrasions to his/her right forehead. The Facility's Investigation, dated 05/10/19, indicated Resident #1, who is not safe to leave the Facility independently, eloped from the Facility without a responsible person on 05/09/19, at approximately 3:45 P.M. The Facility received a call at approximately 4:00 P.M. from a neighbor, who reported that a resident (later identified as Resident #1) was sitting on the ground outside of the Facility. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1's Hospital Medical Record, dated 05/10/19, indicated he/she was diagnosed with [REDACTED]. The Surveyor interviewed the Receptionist at 2:00 P.M. on 06/07/19. The Receptionist said she received a call from an employee who worked at the gas station next door to the Facility. The Receptionist said the employee told her that there was a resident (later identified as Resident #1) sitting on the ground outside of the Facility. The Receptionist said she immediately notified the Administrator of Resident #1's elopement from the Facility. The Surveyor interviewed Nurse #5 at 11:57 A.M. on 06/14/19. Nurse #5 said she worked the day shift (7:00 A.M. to 3:00 P.M.) but had stayed until approximately 4:00 P.M. on 05/09/19 to finish documentation. Nurse #5 said she heard staff talking about Resident #1 being missing from the locked unit so she stayed until he/she was found and brought back to the locked unit. Nurse #5 said she recalled last seeing Resident #1 on the locked unit at approximately 3:15 P.M. while staff discussed a change of shift report. The Surveyor interviewed the Director of Nurses (DON) at 4:55 P.M. on 06/07/19. The DON said some visitors have the security access code to enter and leave the Facility's locked units and my have obtained/received the security access code from staff. The DON said she was unaware of how Resident #1 left the Facility's locked unit, but he/she may have followed a visitor out the door and off the locked unit. 2. Resident #2's Face Sheet indicated he/she was admitted to the Facility in (MONTH) 2019, [DIAGNOSES REDACTED]. Review of Resident #2's clinical record indicated he/she had an Order Appointing Temporary Guardian for an Incapacitated Person, dated 01/29/19, to make medical decisions on his/her behalf. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 05/15/19, indicated he/she had mild cognitive impairment and required supervision for ambulation. Resident #2's Elopement Risk Assessment, dated 03/06/19, indicated he/she was at high risk for an elopement from the Facility. Resident #2's Elopement Care Plan, dated 03/11/19, indicated he/she may attempt to leave the Facility but it is unsafe for him/her to do so due to Resident #2's history of wandering, cognitive decline, and history of elopement. Resident #2's Nursing Progress Note, dated 06/04/19, indicated that Resident #2 was transferred to the hospital due to signs of intoxication. The Note indicated Resident #2 had eloped from the Hospital prior to returning to the Facility. The Facility's Investigation, dated 06/06/19, indicated Resident #2, who was not safe to leave the Facility independently, removed his/her wander guard and eloped from the Facility without a responsible person on 06/06/19 at approximately 2:35 P.M. The Investigation indicated that staff found Resident #2 off Facility grounds and smelling of alcohol so staff called 911, but Resident #2 refused to go to the hospital. The Investigation indicated a few hours later, Resident #2 became verbally abusive and aggressive towards staff, so staff called 911 again and transferred him/her to the hospital. The Investigation indicated Resident #2 returned to the facility on [DATE]. Resident #2's Nursing Progress Note, dated 06/06/19, indicated Resident #2 was attempting to wander into another resident's (of the opposite sex's) bedroom and when redirected, Resident #2 threatened a staff member and said, I will kill you, I will kill you, or words to that effect. Resident #2's Hospital Medical Record, dated 06/06/19, indicated he/she was diagnosed with [REDACTED]. The Surveyor interviewed the Infection Control Nurse at 4:30 P.M. on 06/07/19. The Infection Control Nurse said that while driving around in search of Resident #2, she found him/her at approximately 3:30 P.M. about a quarter of a mile down the road, walking on a side walk towards the Facility. The Infection Control Nurse said she pulled over and had Resident #2 get in her vehicle so she could drive him/her back to the Facility. The Infection Control Nurse said Resident #2 smelled of alcohol when he/she got into her vehicle. Resident #2's Nursing Progress Note, dated 06/06/19, indicated he/she was confused, on 15 minute checks, and had a wander guard placed on his/her wrist. The Note indicated that at approximately 2:35 P.M., Resident #2 was not on the unit, so staff initiated a search and he/she returned to the unit at approximately 3:50 P.M. The Note indicated a skin check was performed and a moderate-sized scratch on Resident #2's upper arm was noted. The Surveyor interviewed Nurse #4 at 4:05 P.M. on 06/07/19. Nurse #4 said Resident #2 went outside for a smoke break at approximately 1:30 P.M. on 06/06/19. Nurse #4 said at approximately 2:35 P.M. staff noticed Resident #2 was not on the unit. Nurse #4 said Resident #2 was supposed to be wearing a wander guard. Nurse #4 said she was unaware how Resident #2 got off the locked unit. The Surveyor interviewed the Director of Nurses (DON) at 4:55 P.M. on 06/07/19. The DON said Resident #2 had a guardian, a known history of Alcohol Dependence, and that she was unsure how he/she got off the unit on 06/06/19. The DON said that once Resident #2 was found and returned to the unit, he/she became behavioral so staff transferred him/her to the hospital, where he/she was found to be intoxicated.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #2), the facility failed to identify the behavioral health care needs and provide the appropriate services necessary to meet the individual care for residents with known substance abuse/use issues. - The Facility failed to ensure each resident received a comprehensive medical and interdisciplinary evaluation to determine the severity of their Substance Use Disorder (SUD) and develop treatment priorities. - The Facility failed to develop, review and revise behavioral health care plans that had not been effective and/or when the resident has a change in condition. - The Facility failed to ensure that residents with SUD had access to substance use services either in the community or within the facility. Findings include: The National Association of Social Workers (NASW) Standards for Social Work Practice with Clients with Substance Use Disorders, issued in 2013, indicated that SUDs included the use of alcohol, tobacco, and other drugs. The Standards indicate that social workers shall: - Conduct ongoing assessments of clients to provide clients with SUDs with appropriate [DIAGNOSES REDACTED]. - Engage in advocacy that seeks to ensure that clients with SUDs and their families have equal access to the appropriate services in a timely manner. - Promote interdisciplinary and inter-organizational collaboration to support, enhance, and deliver effective services to clients with SUDs and their families. Resident #2's Face Sheet indicated he/she was admitted to the Facility in (MONTH) 2019; [DIAGNOSES REDACTED]. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 05/15/19, indicated he/she had mild cognitive impairment and required supervision for ambulation. Order Appointing Temporary Guardian for an Incapacitated Person, dated 01/29/19, indicated Resident #2 had a temporary Guardian to make medical decisions on his/her behalf. 1. Resident #2's Nursing Progress Note, dated 06/04/19, indicated that Resident #2 was agitated, verbally abusive to staff, had slurred speech and an unsteady gait. The Note indicated staff found a water bottle filled with alcohol and he/she was transferred to the hospital. The Note indicated Resident #2 eloped from the Hospital prior to returning to the Facility. The Surveyor interviewed Nurse #4 at 4:05 P.M. on 06/07/19. Nurse #4 said she wrote the Nursing Progress Note, dated 06/04/19. Nurse #4 said that on 06/04/19, staff found a water bottle of alcohol in Resident #2's bedroom and he/she was transferred to the hospital due to signs of intoxication. Resident #2's Hospital Medical Record, dated 06/04/19, indicated he/she had an [MEDICATION NAME] level of 170 milligram (mg)/deciliter (dl) (300-400 mg/dl can cause unconsciousness, [MEDICAL CONDITION], and death). 2. The Facility's Investigation, dated 06/06/19, indicated Resident #2, who was not safe to leave the Facility independently, removed his/her wander guard and eloped from the Facility without a responsible person at approximately 2:35 P.M. on 06/06/19. The Investigation indicated the Facility staff found Resident #2 off Facility grounds and smelling of alcohol, so staff called 911 but Resident #2 refused to go to the hospital. The Investigation indicated a few hours later, Resident #2 became verbally abusive and aggressive towards staff, so staff called 911 again and transferred him/her to the hospital. The Surveyor interviewed Nurse Practitioner (NP) #2 at 1:15 P.M. on 06/18/19. The NP said staff notified her of Resident #2's elopement from the Facility on 06/06/19. The NP said staff informed her that Resident #2 appeared under the influence of alcohol and he/she refused to go to the hospital for an evaluation. The NP said Resident #2 had a Guardian but since he/she refused to go to the hospital, the plan was to monitor and contain Resident #2 at the Facility. The NP said Resident #2 became verbally aggressive towards staff; therefore, he/she was transferred to the hospital later that evening. Resident #2's Hospital Medical Record, dated 06/06/19, indicated he/she was diagnosed with [REDACTED]. Review of Resident #2's Care Plan indicated that interventions for Alcohol Use and/or Alcohol Dependence was not included until 06/08/19, which was four days after Resident #2 first consumed alcohol while at the Facility. The Surveyor interviewed the Director of Nurses (DON) at 4:55 P.M. on 06/07/19. The Director of Nurses said Resident #2's Care Plan should have been updated after the incident(s) that occurred on 06/04/19 and 06/06/19, to address Resident #2's Alcohol Dependence and Alcohol Use at the Facility. There was no documentation at the time of survey that Resident #2, who was admitted with a [DIAGNOSES REDACTED].#2 and/or his/her representative to address Resident #2's SUD needs.

Based on record review and interview, the Facility failed to follow physicians' orders to administer the correct medications and correct dosages for 2 of 24 sampled residents (Resident #6 and Resident #179). From 4/20/18 to 6/18/18, nursing staff administered [MEDICATION NAME] 300 milligrams (mg) three times a day to Resident #179. On 5/1/18, Staff Nurse #2 administered [MEDICATION NAME]to Resident #6, instead of the prescribed [MEDICATION NAME] insulin. Findings include: The Facility Policy for Reconciliation of Medication on Admission indicated the following: -review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage from the previous MAR. -if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. contact the nurse from the referring facility b. contact the physician from the referring facility c. contact the primary physician in the community d. discuss with the resident or family 1. Resident # 179 was admitted to the facility on ,[DATE], for ongoing medical management and short term rehabilitation following ankle surgery. Resident #179 had [DIAGNOSES REDACTED]. Resident #179's referral orders from Brigham & Women's(NAME)Hospital post ankle surgery indicated:: [MEDICATION NAME] take 100 mg by mouth 3 (three) times a day [MEDICATION NAME] ([MEDICATION NAME]) 100 MG TABLET: Dose: 300 MG: FORM: Take 3 TABLET; Route: PO Frequency: QHS Duration: 30 day(s); Dispense: 90 tablets Resident #179's Physician Telephone Order, dated 4/19/18, indicated admit Resident to Vero Health care, all admitting medications (including: [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 100 mg 3 TABLET (300 mg) THREE TIMES DAILY), treatment and all ancillary orders confirmed. Resident #179's Medication Administration Record [REDACTED] - from 4/20/18 to 4/30/18, indicated nursing staff administered [MEDICATION NAME] 300 mg three times a day at 6 A.M., 2 P.M., and 10 P.M. - from 5/1/18 to 5/16/18, indicated that nursing staff administered [MEDICATION NAME] 300 mg three times a day at 6 A.M., 2 P.M., and 5 P.M. On 5/17/18 Resident #179's Initial Psychiatric Evaluation indicates review of medication including [MEDICATION NAME] 300 mg three times a day. No medication changes. Resident #179's Physician Telephone Order, dated 5/17/18, indicated clarification of order, change [MEDICATION NAME] time to 6 A.M., 2 P.M., 10 P.M., space doses 8 hours apart. Resident #179's Medication Administration Record [REDACTED] - from 5/17/18 to 6/18/18, indicated that nursing staff administered [MEDICATION NAME] 300 mg three times a day at 6 A.M., 2 P.M.,and 10 P.M. Resident # 179's nurses notes, dated 6/18/18 for the 7:00 A.M. to 3:00 P.M. shift, indicated Resident #179 was very confused, unable to stand up on his/her feet, unable to focus, had a floppy tongue, rolled his/her eyes, but was not in respiratory distress. Nursing staff notified the Nurse Practitioner (NP) and the NP gave an order to send Resident #179 to the Emergency Department for further evaluation. The Hospital Emergency Department report indicated that on medical record review, it was found that the facility had been giving Resident #179 [MEDICATION NAME] 300 mg THREE TIMES A DAY, which is not the Resident's home dose (Resident's home dose is 300 mg once/day at bedtime). The Hospital report indicated that Resident #179 was hospitalized for [REDACTED]. During the hospitalization , Resident #179 was monitored closely fror [DIAGNOSES REDACTED] (NMS) which includes [MEDICAL CONDITION] rigidity, and fever, altered mental status, and nervous system dysfunction. Blood testing was also done for [MEDICATION NAME] levels 6/18/18 and 6/19/18, both markedly elevated at 1900 (greater than 100 can lead to central nervous system side effects such as impaired concentration, confusion, abnormal thinking, anxiety, and drowsiness). The Surveyor interviewed the Unit Manager (UM) #2 on 4/19/18 at 9:30 A.M. UM #2 said that Resident #179's Hospital summary of medication was poorly written with large bold print, and the medication orders were highlighted. UM #2 said that she followed the bold instruction and wrote the order for [MEDICATION NAME] 100 mg 3 tabs (300 mg) PO three times a day. The Surveyor asked UM #2 if she telephoned the discharging Hospital for clarification, and she replied No, I should have,. UM #2 indicated that she and the other Facility nurses did review Resident #179's MAR from the Hospital. The Surveyor interviewed the Director of Nursing (DON) on 7/27/18 at 11:30 A.M. The DON said that a transcription error occurred involving Resident #179. The DON said that when he saw the medication order, right away he had a question about it and it needed clarification. The DON said that when there is an admission to the Facility the policy is for 2 nurses to review the admission papers, reconcile medications/treatments and for the 11:00 P.M. to 7:00 A.M. nurses to continue to review the admission summary and review all the medication/treatments. The DON said that Facility staff did review the medication orders, but did not seek to clarify the [MEDICATION NAME] order. The DON also said that Resident 179 was seen by a Psychiatrist on 5/17/18 and reviewed all the medications, no changes were made. 2. For Resident #6, the facility failed to transcribe a Physician order [REDACTED].#6 receiving wrong medication. Resident #6 was admitted to the Facility in 4/2018, with [DIAGNOSES REDACTED]. Resident #6's medical record indicated that on 5/1/18, Staff Nurse #2 notified the Nurse Practitioner (NP) that Resident #6's blood glucose reading was HIGH. The NP gave an order, dated 5/1/18, to administer 7 units of [MEDICATION NAME](a fast-acting insulin absorbed quickly into the blood stream), to be administered one time. Resident #6's Medication Administration Record [REDACTED].M., instead of [MEDICATION NAME]as the NP ordered. Further review of Resident #6 medical record dated 5/1/18 indicated that the nurse later rechecked the blood sugar level and got a result of 491 after administering 7 units of [MEDICATION NAME] insulin. The nurse's notes did not indicate if the physician was notified of this result. On 5/2/18 11-7 shift, the nurses notes indicated that Resident #6 was restless, disoriented, had difficulty answering simple questions. The nurse checked Resident #6's blood glucose level and got results of 494. The Physician was notified and gave an order to send Resident #6 to the Emergency Department for evaluation and treatment. The Surveyor interviewed the Director of Nursing (DON) on 7/31/18 at 1:30 P.M. The DON said that he was not aware of this transcription error until the Surveyor brought it to his attention. The DON said that Staff Nurse #2 was unavailable for interview because she was currently on vacation and out of the country.