Every finding on record at Colony Center for Health and Rehabilitation

Based on interview and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#5), out of a total sample of 18 residents, resulting in a decline in medical status and hospitalization. Specifically, the facility failed to ensure staff assessed and managed gastrointestinal symptoms indicative of constipation, resulting in hospitalization for stercoral colitis (inflammation of the intestinal walls caused by hardened stool in the colon) and fecal impaction (a severe form of constipation where stool becomes stuck in the colon/rectum).Findings include:Review of the facility's policy titled Bowel Regimen, revised 2/2024, indicated, but was not limited to, the following:-CNA (Certified Nursing Assistant) is responsible for accurate documentation of bowel movements at the end of each shift on the Electronic Medical Record.-The Charge Nurse reviews the Bowel Movement Record at the beginning and end of each shift for residents in need of the bowel regime.-All residents will have an MD order (if not contraindicated or per resident/provider preference) that reads as follows unless otherwise specified by a physician:1. MOM (Milk of Magnesia, an over-the-counter laxative medication) 30 cc (cubic centimeters) PO (by mouth) PRN (as needed) if no BM (bowel movement) after six (6) shifts2. Dulcolax suppository (an over-the-counter laxative medication) 10 mg (milligrams) PR (per rectum) PRN if MOM ineffective3. Fleet enema (an over-the-counter rectal agent that increases water in the intestine, which promotes a bowel movement) one PR PRN if Dulcolax suppository ineffectiveReview of the facility's policy titled Resident Examination and Assessment, revised 7/2025, indicated, but was not limited to, the following:-Notify the physician of any abnormalities such as, but not limited to: distended, hard abdomen or absence of bowel soundsResident #5 was admitted to the facility in July 2023 with diagnoses including constipation and stroke.Review of Resident #5's Minimum Data Set (MDS) assessment, dated 5/19/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated the Resident was always incontinent of bowel and dependent on staff for toileting hygiene. Review of Resident #5's Care Plan indicated, but was not limited to, the following:-Focus: [Resident #5] has constipation r/t (related to) decreased mobility, diminished appetite, pain, poor fluid intake, use/side effects of medication (date initiated: 4/7/24)-Goal: [Resident #5] will have a normal bowel movement at least every 3 days through the review date (date initiated: 4/7/24); [Resident #5] will pass soft, formed stool at the preferred frequency 1-3 days through the review date (date initiated: 4/7/24)-Interventions: Monitor/report complaints of abdominal pain, distention and n/v (nausea/vomiting) report to Nurse [sic] (date initiated: 4/7/24); Monitor/document/report PRN s/sx (signs/symptoms) of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, bradycardia (slow, low pulse), abdominal distention, vomiting, small loose or stools [sic], fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding, rigidity, fecal compaction (date initiated: 4/7/24); Monitor medications for side effects of constipation. Keep physician informed of any problems (date initiated: 4/7/24)Review of Resident #5's electronic medical record indicated the Resident was hospitalized in November 2025 and February 2026. Review of the hospital Discharge summary, dated [DATE], indicated Resident #5 was sent to the emergency department with abdominal distention (swollen abdomen). The Resident was found to have constipation with abdominal CT (Computed Tomography, an imaging test the uses x-rays and computer technology to create detailed images of the body) scan showing moderate stool with focal colitis (inflammation of the colon, or large intestine, the final part of the digestive system). The Resident was discharged back to the facility on scheduled daily Miralax (a laxative medication) and as needed Milk of Magnesia, Dulcolax suppository, and Fleet enema per facility protocol.Review of Resident #5's Nurses Notes indicated that on 1/28/26, the Resident was noted to have abdominal distention with positive bowel sounds. Further review of the Nurses Notes indicated on 2/2/26, the Resident presented with nausea and vomiting and was transferred to the hospital for evaluation. The Nurses Notes failed to indicate further assessment or management of the Resident's abdominal distention noted on 1/28/26 until he/she was transferred to the hospital after vomiting on 2/2/26. Review of the Resident's Documentation Survey Report for January 2026 and February 2026 indicated that prior to his/her transfer to the hospital on 2/2/26, Resident #5 had had a medium, formed bowel movement on 1/28/26 during the night shift; a small, formed bowel movement on 1/28/26 during the day shift; and a small, formed bowel movement on 1/31/26 during the day shift. Review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2026 and February 2026 indicated the Resident did not receive any of his/her ordered as needed bowel medications between 1/28/26 and 2/2/26. Review of the hospital Discharge summary, dated [DATE], indicated Resident #5 was sent to the emergency department with nausea and coffee-ground emesis (vomit that resembles coffee grounds). The Resident was found to have stercoral colitis and severe impacted stool and received an aggressive bowel regimen with two large bowel movements and significant clinical improvement. The Resident's medication regimen was changed by the hospital to include a Dulcolax Suppository 10 mg PR three times weekly (scheduled) before he/she was discharged back to the facility.During an interview on 5/28/26 at 2:09 P.M., Certified Nursing Assistant (CNA) #5 said the CNAs document residents' bowel movements in the electronic health record every shift. CNA #5 said if a resident has not had a bowel movement, the nurse receives an alert and would notify the CNA that no bowel movement had been documented.During an interview on 5/28/26 at 2:10 P.M., Nurse #5 said Resident #5 had been hospitalized a couple of times with fecal impaction and now receives a suppository every 72 hours scheduled as a preventative measure. Nurse #5 said she could not recall specifics around Resident #5's hospitalization on 2/2/26, but if there were signs that the Resident was constipated, such as abdominal distention, bowel regimen medications should have been administered, and the doctor should have been contacted if the medications were not effective in relieving constipation. During an interview on 5/28/26 at 2:15 P.M., Resident #5 said he/she recalled going to the hospital in February but could not remember why. Resident #5 could not recall if he/she was constipated but reported he/she has not had further issues moving his/her bowels since returning from the hospital.During an interview on 5/28/26 at 2:32 P.M., the Director of Nursing (DON) said she did not work at the facility when Resident #5 was hospitalized in February 2026 and was not familiar with the circumstances of the transfer. The DON said nurses should initiate the facility's bowel protocol (Milk of Magnesia, Dulcolax suppository, Fleet enema) if a resident has not had a bowel movement in three days.During a telephonic interview on 6/1/26 at 10:33 A.M., Physician #1 said it was his expectation that when Resident #5 presented with abdominal distention, as needed bowel regimen medications would be administered until the Resident had an adequate bowel movement and was no longer symptomatic of constipation. Physician #1 said he did not recall being notified of any abnormal physical assessment findings for Resident #5 before he/she was noted to be vomiting and sent to the hospital. During a telephonic interview on 6/1/26 at 4:25 P.M., Nurse #6 said Resident #5 often had abdominal distention. Nurse #6 said when the Resident was distended, she would check his/her bowel sounds and ask the CNAs if the Resident had moved his/her bowels. Nurse #6 said Resident #5 is on a bowel regimen and when he/she was distended, she would only administer as needed bowel medications if the Resident requested them and would otherwise just monitor him/her.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#13), out of a total sample of 18 residents. Specifically, the facility failed to obtain daily weights as ordered by the Nurse Practitioner (NP) for a Resident with significant weight variances of a weight loss of 19% in a three-month period, and a weight gain of 5.5% in a one-month period.Findings include:Review of the facility's Weight Assessment and Intervention policy, undated, indicated but was not limited to the following:-Resident weights are monitored for undesirable or unintended weight loss or gain.-Weights are recorded in the individual's medical record.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.-If the weight is verified, nursing will immediately notify the dietitian.-Residents are weighed upon admission and at intervals established by the interdisciplinary team (IDT).-Weights are recorded in the individual's medical record. Review of the facility's policy titled Medication and Treatment Orders, undated, indicated, but was not limited to, the following:-Orders for medications and treatments will be consistent with principles of safe and effective order writing-Verbal orders must be recorded immediately in the resident's chart by the person receiving the order. Resident #13 was admitted to the facility in December 2025 with diagnoses including Congestive Heart Failure (CHF), Acute Kidney Failure, and Type 1 diabetes. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 3/24/26, indicated Resident #13 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.Review of Section K Swallowing/Nutritional Status of the MDS assessment indicated Resident #13 sustained a weight loss of 5% or more in last month or 10% or more in past 6 months and was not on a prescribed weight-loss regimen, and sustained a weight gain of 5% or more in last month or 10% or more in past 6 months and was on a prescribed weight-loss regimen. During an interview on 5/26/26 at 9:02 A.M., Resident #13 said he/she usually consumes 100% of their meals. Resident #13 said the staff is supposed to obtain his/her weight daily, but it does not always happen. Review of Resident #13's Physician's Orders in the electronic health record (EHR) indicated, but was not limited to, the following:-Daily weights x 7 days then notify Medical Doctor (MD) MD/NP to see if daily weights should continue. Notify MD/NP if weight change of three pounds (lbs.) in two days or 5 lbs. in one week; until 1/18/26 for Congestive Heart Failure (CHF). Start date (1/10/26), discontinued 1/18/26.-Monitor daily weight for weight gain, please call MD for weight gain of 3 lbs. or more in four or five times in one week. One time a day for weight gain for acute kidney failure. Start date (2/14/26).Further review of the Physician's Orders failed to indicate an order was in place for daily weights from 1/19/26 through 2/13/26. Review of Resident #13's Physician's Orders in the paper record indicated telephone orders were written for the following:-1/9/26: Check daily weight at 6:00 A.M., prior to breakfast and after am void (urination). Contact NP if weight gain of 3 lbs. in 24 hours or 5 lbs. in one week.-1/16/26: Weights not done daily, please add, was admission correct 252 lbs. now 218 lbs. on 1/15/26.-2/13/26: No weights since 1/18/26. Daily weights ordered 1/9/26. Daily weights at 6:00 A.M., prior to breakfast and after am void. Call with gain of 3 lbs. in 24 hours or 5 lbs. in one week.Review of the weight record indicated the following weights were obtained for Resident #18:12/19/25: 252.0 lbs.1/9/26: 250.1 lbs.1/11/26: 217.2 lbs.1/12/26: 217.2 lbs.1/14/26: 219.2 lbs.1/15/26: 218.1 lbs.1/17/26: 219.4 lbs.1/18/26: 218.6 lbs.2/15/26: 190.0 lbs.2/16/26: 187.9 lbs.2/18/26: 209.4 lbs.2/18/26: 209.4 lbs.2/18/26: 210.2 lbs.2/19/26: 200.0 lbs.2/22/26: 201.1 lbs.2/23/26: 199.0 lbs.2/24/26: 199.5 lbs.2/25/26: 199.0 lbs.2/26/26: 199.8 lbs.2/28/26: 202.0 lbs. Review of Resident #13's January and February 2026 Medication Administration Records (MARs) indicated the following:-No weight was obtained 1/19/26 through 2/13/26.-No weight was obtained on February 17, 20, 21 and 27, 2026. Documented reason on the MAR: other/see nursing notes.Review of the nursing progress notes failed to indicate why the weights were not obtained January 19 through February 13, 2026, February 17, 20, 21, 27, 2026.Further review of the progress notes failed to indicate the physician had been notified of 3 lb. weight variances.Review of the NP progress notes indicated the following:-1/9/26: Add daily weights at 6:00 A.M. prior to breakfast and after a void; contact NP/MD if gain 3 lbs. in 24 hours or 5 lbs. in one week.-1/16/26: Added daily weights at 6:00 A.M. prior to breakfast and after a void, contact NP/MD if gain 3 lbs. in 24 hours or 5 lbs. in one week. These weights were not obtained and appears they have been checked weekly. There is a big discrepancy in his/her weight on admission he/she was 252 lbs. and on January 15, 2026, 218 lbs. Unclear of the admission weight is correct. Nursing is looking into this.-2/13/26: Added daily weights at 6:00 A.M. prior to breakfast and after a void, contact NP/MD if gain 3 lbs. in 24 hours or 5 lbs. in one week. These weights were not obtained. There is a big discrepancy in his/her weight on admission he/she was 252 lbs. and on January 15, 2026, 218lbs. Unclear of the admission weight is correct. Nursing is still looking into this. Review of the most recent Nutrition Quarterly Assessment, dated 3/24/26, indicated but was not limited to the following:-weight: 212 lbs.-triggered for a significant weight gain of 5.5%. 13 lbs. in 30 days-triggered for a significant weight loss of 19%. 40 lbs. in 90 days.-received double protein portions for all meals-received liquid protein supplement twice a day-received Glucerna shakes twice a day in between meals. Review of Resident #13's care plan indicated but was not limited to the following:Focus:-Nutritional problem or potential nutritional problem related to weight has fluctuated from 252 lbs. (12/19/25) at admission to 199 lbs. (2/23/26) to 212 lbs. (3/23/26), maybe related to diuretic therapy, as well as resident states that he/she enjoys the food but is cutting back a little states that he/she would like to lose a little more weight, agreed goal is weight stabilization. Date Initiated: 01/02/2026Goals:-He/she will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 212 lbs., no signs or symptoms of malnutrition, and consuming at least 75% of meals, snacks and supplements. daily through review date. Date Initiated: 02/15/2026Interventions:-Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow-up as indicated. Date Initiated: 01/02/2026- Registered Dietitian to evaluate and make diet change recommendations PRN. Date Initiated: 01/02/2026 During an interview on 5/27/26 at 12:18 P.M., Certified Nursing Assistant (CNA) said the nurse tells her what residents need to be weighed on her shift during morning report and will sometimes put it on her assignment sheet. She obtains weight and gives it to the nurse. She does not document the weight in the medical record. During an interview on 5/27/26 at 12:26 P.M., Nurse #1 said when a resident has weight change of 3 lbs. from the previous weight, she will ask the CNA to obtain a re-weight, that is a standing order. She said if the weight change is valid, she will notify her manager, and the physician or NP. During an interview on 5/27/26 at 12:54 P.M., the Registered Dietitian (RD) said she was not working at this facility when Resident #13 was admitted . She said she does not feel the admission weight was accurate and with his/her significant weight loss and gain it is very confusing. The RD said she has met with the Resident and he/she looks good and she goes by that as well. She said there are supplements in place to stabilize the Resident's weight fluctuations. The RD said many daily weights were not obtained as ordered, and the discrepancies in weights should have been resolved to determine if there has been an actual significant weight loss or gain. During an interview on 5/27/26 at 1:31 P.M., NP #1 said Resident #13 has a diagnosis of CHF and she wanted to monitor his/her weights closely, so she gave an order for daily weights. She said when her order was not implemented, she ordered it again the following week. NP #1 said the order in the paper record and the order in the EHR are not the same and the order in the EHR is inaccurate. NP #1 said it is difficult for her to determine if the Resident has had an actual weight loss or gain with the weights that are in the medical record. During an interview on 5/27/26 at 3:44 P.M., the Director of Nursing (DON) said all new admissions are to have their weight obtained upon admission, then weekly for four weeks, unless otherwise ordered by the physician or NP. The DON said if a weight is off by 3 lbs. a re-weigh is obtained. She said if the weight continues to be off, the MD/NP must be notified. The DON said when a practitioner gives an order her expectation is the order to be transcribed as given and not changed. The DON reviewed current weight order and weight summary for Resident #13 in the EHR and said the order in the system is not what the NP ordered and is inaccurate. She said many daily weights are missing. The DON said the Resident does not have consistent daily weights documented in the chart, and it is difficult to determine the accuracy of the weight.

Based on interview and record review, the facility failed to ensure the comprehensive care plan included the participation of residents and representatives. Specifically, the representatives for Resident #65 and Resident #3 had not been invited to participate in scheduled quarterly care plan meetings with the interdisciplinary team (IDT), attendees of Resident Council were unaware of the care planning process and only representatives with email addresses were invited to participate. Findings include:1. Resident #65 was admitted to the facility in June 2023. Review of the medical record indicated Resident #65 had an activated Health Care Proxy (HCP). During an interview on 5/26/26 at 12:41 P.M., the HCP of Resident #65 said she was not invited to care plan meetings quarterly and there had been no meetings with staff in which different disciplines attended. Review of the electronic medical record included evaluations titled Care Plan Meeting IDT. Review of the evaluations for Resident #65 included two Care Plan Meetings, one on 8/7/25 and one on 4/2/26, both marked as incomplete. Review of the Care Plan Meeting from 8/7/25 indicated sections were only completed by the Therapy Department and the Activity Department; sections for Nursing, Dietary, Social Services and list of Attendees were all blank. Review of the Care Plan Meeting from 4/2/26 indicated the Attendees included the HCP of Resident #65 by phone. During an interview on 5/26/26 at 5:03 P.M., the HCP of Resident #65 said she did not attend any meeting by phone in April 2026 and reiterated that she had never received any invitations to attend care plan meetings. She said there were things she would like to go over in the care plan meetings such as figuring out how to get the Resident a hair cut as this had been difficult to coordinate. During an interview on 5/27/26 at 2:21 P.M., the Activity Director said she attended care plan meetings every week. She said she was not involved in the invitation process for care plan meetings and that was the responsibility of the Social Service Department. She said she could not recall the HCP of Resident #65 being on the phone during a meeting the month prior. 2. Resident #3 was admitted to the facility in April 2025. Review of the medical record indicated Resident #3 had an activated HCP. During an interview on 5/26/26 at 1:03 P.M., the HCP of Resident #3 said he did not know anything about care plan meetings and was not invited quarterly. Review of the Care Plan Meeting from 1/29/26 indicated the Attendees included the HCP of Resident #3 by phone. Review of the Care Plan Meeting from 4/2/26 indicated sections were only completed by the Therapy Department, Dietary Department and the Activity Department; sections for Nursing, Social Services and list of Attendees were all blank. 3. During a group meeting held with members of the Resident Council on 5/27/26 at 11:10 A.M., 11 out of 11 residents said they did not know what care plan meetings were and had never been invited to participate. During an interview on 5/27/26 at 3:19 P.M., the previous Social Worker said they had stopped employment with the facility about two weeks prior. The Social Worker said the process was for the Social Services Department to get the scheduled assessment list from the MDS (Minimum Data Set) Coordinator and then meetings would be set up with the IDT on Thursdays afternoons. He said the previous Administrator was helping to send out the invitations and it became difficult to send out invitations when that person left. He said no invitations were being mailed to representatives, but if there was an email address on file, they were being emailed. He said the representatives without email addresses were not mailed invitations. He said if a Resident was their own responsible person he would go to their room and invite them and could not say why the Resident Council members did not know what a care plan meeting was. During an interview on 5/28/26 at 1:13 P.M., the Administrator said the process was for the Social Service Department to send out invitations to representatives and invite residents to care plan meetings. He said the previous Social Worker had been instructed to send out care plan invitations. He said he was aware that email invitations were being sent to representatives but was not aware that if the representative did not have an email address, they were not being invited. He said all residents and representatives should have been invited to participate in the care plan process.

Based on interview and record review, the facility failed to ensure the recommendations from the Department of Mental Health (DMH) Preadmission Screening and Resident Review (PASRR) level II Evaluation Determination for one Resident (#1), of 18 sampled residents, were implemented and incorporated into the Resident's assessment and care planning. Specifically, the facility failed to ensure Resident #1, determined to have a serious mental illness (SMI) including a history of self-harm, continued to receive individual psychotherapy and had goals of care which reflected the SMI. Findings include:A PASRR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disorder (MD), intellectual disability (ID) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitation services the individual needs. Resident #1 was admitted to the facility in [DATE] with a diagnosis of major depressive disorder, severe with psychotic features following a five-month inpatient psychiatric hospitalization. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating a moderate cognitive impairment. Review of the medical record indicated Resident #1 was evaluated in the hospital to need specialized services through the PASRR Level II Evaluation Determination which expired on [DATE]. As of [DATE], no further PASRR determinations were located in the paper or electronic medical record for Resident #1. Upon request, the surveyor was provided with a PASRR level II Evaluation Determination, dated [DATE], from the electronic PASRR portal. The evaluation indicated Resident #1 had a SMI with a history of multiple inpatient psychiatric hospitalizations and a history of suicide attempts by overdose, cutting wrists, walking in front of a moving vehicle, ingesting poison and taping fists/punching self. The evaluation indicated the behavioral health and required specialized services included individual psychotherapy and that the Resident would benefit from psychotherapy to reduce isolation, offer emotional support/validation and maintain mental health. The evaluation indicated due to a history of behavioral concerns the Resident would require and benefit from behaviorally based treatment plans/interventions. Review of Resident #1's care plans indicated the Resident had a Level II PASRR in place which expired on [DATE] with interventions for one to one (1:1) therapy. As of [DATE], no updated information was reflected on the care plan following a subsequent PASRR review on [DATE], nine months prior. Review of the care plans included information regarding Resident #1 taking psychiatric medications with interventions to administer medications as ordered, monitor behaviors and monitor medication side effects. None of the care plans reflected personalized interventions for Resident #1's history of suicide attempts and psychiatric hospitalizations. Review of the medical record indicated Resident #1 received 1:1 psychotherapy which indicated but was not limited to:[DATE]: Resident is very sad to be at nursing home[DATE]: discussed how parent brutally physically abused him/her and has had night terrors[DATE]: discussed horrible childhood[DATE]: maybe a little less anxiety I guess[DATE]: therapist notes: I will see him again, but if {he/she} reports no significant anxiety again, I will start seeing {him/her} as needed but no longer for ongoing psychotherapy. The surveyor requested all subsequent 1:1 psychotherapy visits from the facility and no additional visits were provided. Review of the consultant psychiatric Nurse Practitioner (NP) notes indicated the following:[DATE]: continues to lack motivation and insight, needs encouragement and support and was responding well to 1:1 therapy; discussed psychotherapist retiring and a new therapist coming During an interview on [DATE] at 3:05 P.M., the Assistant Director of Nurses said the 1:1 psychotherapist retired at the beginning of the year and the psychiatric NP was not providing therapy to residents, only medication management. During an interview on [DATE] at 3:17 P.M., the Administrator said the previous 1:1 psychotherapist retired and he was not sure if there was a hand-off to the facility staff on what the plan was for residents who needed 1:1 psychotherapy. He said as far as he knew, no attempts had been made for coordination of services outside of the facility. He said the previous Social Worker may know as they had coordinated with psychiatric services. During an interview on [DATE] at 3:20 P.M., the previous Social Worker said he had left the facility a couple of weeks prior. He said the previous 1:1 psychotherapist had retired at the beginning of the year, and the facility had attempted to get another psychotherapist for individual counseling but had not as of when he had left. He said there were about 12 residents at the facility who were in need of individual psychotherapy and Resident #1 was one of the residents. He said he had not coordinated any additional attempts for psychotherapy for Resident #1. He said he could not remember much about Resident #1's history and could not provide more information. He said if there was a psychiatric history it should be reflected on the care plans. During an interview on [DATE] at 10:43 A.M., the Psychiatric NP said she sees residents at the facility for psychotropic medication management and does not see residents for 1:1 psychotherapy. She said Resident #1 was frail both in terms of mood and medical. She said the Resident benefitted from 1:1 psychotherapy because it was good to have social engagement. She said she was not sure if psychotherapy terminated because it was no longer needed or because the therapist was leaving. During an interview on [DATE] at 11:55 A.M., Resident #1 said he/she previously was seeing a psychotherapist and added the dancing doctor. The Resident said he/she liked to talk to him and found it helpful. During an interview on [DATE] at 2:51 P.M., the legal guardian for Resident #1 said the Resident had a significant psychiatric history including self-harm and he expects the Resident to be receiving 1:1 psychotherapy in addition to medication management. Refer to F740

Based on interview and record review, the facility failed to follow professional standards of practice for two Residents (#52, #2), out of a total sample of 18 residents. Specifically, the facility failed:1. For Resident #52, to follow manufacturer's guidelines for administration of an extended-release medication; and2. For Resident #2, to implement physician's orders to reduce the Resident's dose of Levothyroxine (a medication used to treat hypothyroidism by supplementing thyroid hormone).Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.1. Review of the facility's policy titled Administering Medications, undated, indicated, but was not limited to, the following:-The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.-Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance Performance Improvement) committee to inform process changes and or the need for additional staff training.Resident #52 was admitted to the facility in September 2022 with diagnoses including hypertension (high blood pressure) and dementia.Review of Resident #52's Physician's Orders indicated, but was not limited to, the following:-Metoprolol Succinate Extended Release 24 hour Give 6.25 milligrams (mg) by mouth one time a day for hypertension, hold for systolic blood pressure below 100 and heart rate below 60 (order date 12/12/25)On 5/27/26 at 9:33 A.M., the surveyor observed Nurse #2 prepare and administer Resident #52's morning medications. During medication preparation, Nurse #2 poured the Resident's morning medications, including Metoprolol Succinate, from the medication cup into a medication crushing pouch, crushed the medications, and mixed the medications in applesauce and administered it to the Resident.Review of the manufacturer's prescribing information for metoprolol succinate indicated, but was not limited to, the following:-Metoprolol succinate extended-release tablets are scored and can be divided; however, do not crush or chew the whole or half tablet.During an interview on 5/27/26 at 2:03 P.M., Nurse #2 said she did not know the Metoprolol Succinate should not be crushed. During an interview on 5/27/26 at 2:06 P.M. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the ADON said Nurse #2 had informed her that she had crushed Resident #52's medications, including Metoprolol Succinate. The DON said long-acting medications should not be crushed.2. Review of the facility's policy titled Medication and Treatment Orders, undated, indicated, but was not limited to, the following:-Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. -Verbal orders must be recorded immediately in the resident's chart by the person receiving the order.Resident #2 was admitted to the facility in April 2026 with diagnoses including hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone, resulting in symptoms such as weight gain, fatigue, and high cholesterol levels). Review of Resident #2's Minimum Data Set (MDS) assessment, dated 4/29/26, indicated the Resident was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15.Review of Resident #2's laboratory results indicated that on 5/21/26, the Resident's Thyroid-stimulating hormone (TSH, a hormone produced by the pituitary gland to regulate thyroid hormone production) level was low at 0.08 micro-International Units per milliliter (uIU/ml). Review of Resident #2's Physician Progress Note, dated 5/22/26, indicated the physician ordered to decrease the Resident's Levothyroxine dose from 175 micrograms (mcg) daily to 150 mcg daily due to lab results indicating overmedication with thyroid hormone.Review of Resident #2's Physician's Orders indicated, but was not limited to, the following:-Levothyroxine 175 mcg Give 1 tablet by mouth one time a day (start date: 4/24/26, end date: 5/16/26)-Levothyroxine 175 mcg Give 1 tablet by mouth in the evening (start date: 5/16/26, end date 5/19/26)-Levothyroxine 175 mcg Give 1 tablet by mouth one time a day (start date: 5/20/26, end date: 5/21/26)-Levothyroxine 175 mcg Give 1 tablet by mouth one time a day (start date: 5/22/26, end date: 5/26/26)-Levothyroxine 175 mcg Give 1 tablet by mouth one time a day (start date: 5/27/26, end date 5/28/26)Review of Resident #2's Physician's Orders failed to indicate the Resident's Levothyroxine dose was decreased to 150 mcg daily as indicated by the physician on 5/22/26. During an interview on 5/28/26 at 2:32 P.M., the DON said she started the position of the DON on 5/22/26 but had been the Unit Manager on the East Unit, where Resident #2 resides, since 4/1/26. The DON said it is the facility's protocol to enter physician's orders into the electronic medical record immediately.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of individual activities designed to meet the interests of one Resident (#1), out of 18 sampled residents. Specifically, the facility failed to ensure Resident #1 was provided with a meaningful and engaging activity program, including materials for self-directed activity based on their comprehensive assessment and identified preferences. Findings include:Resident #1 was admitted to the facility in May 2025 with a diagnosis of major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 5/13/26, indicated Resident #1 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating a moderate cognitive impairment. Review of the most recent Activities Quarterly assessment dated [DATE], six months prior to review, indicated Resident #1 prefers to keep to him/herself. On 5/26/26 at 10:46 A.M., the surveyor observed Resident #1 in bed with his/her head tilted in the direction of their roommate's television (TV) which was to their left, on their roommate's bureau. Resident #1 did not have a TV, radio or personal effects on their side of the room. Review of the electronic and paper medical record failed to include a social history to indicate the Resident's past experiences. Review of the admission Activity Assessment, dated 5/7/25, indicated Resident #1 liked Bingo, music, and talking with others. During an interview on 5/27/26 at 9:05 A.M., Resident #1 said he/she had been staying in bed since their most recent hospitalization, three months prior. Resident #1 said he/she would like to be more active, but has been staying in bed and watching his/her roommate's TV. The Resident said he/she cannot control what they watch on TV since it was not theirs. He/she said they love! music. The Resident said there was no radio in their room. During an interview on 5/27/26 at 2:10 P.M., the Activity Director said Resident #1 was very quiet and despite early discussions about attending group activities the Resident had never attended. She said the Resident prefers to stay in his/her room and watch TV. She said she did not know if the Resident had or wanted their own TV and maintenance had completed an audit for this. She said Resident #1 had said during their initial assessment that they liked music but she was not sure if anyone had ever turned on music for the Resident. She said the activity staff had recently started doing one to one (1:1) visits with residents and there was a book with the information. She said following the initial assessment she was not sure if she had ever asked the Resident about activities that could be provided in his/her room that would include his/her interests and personal history. During an interview on 5/28/26 at 8:50 A.M., the Activity Director said Resident #1 was added to the activity department 1:1 visit list during the week of 4/22/26, almost one year since admission. She said the facility had recently started visiting residents who were not attending activities to offer additional engagement. During an interview on 5/28/26 at 8:53 A.M., Activity Assistant #1 reviewed the 1:1 activities form with the surveyor. She said she had completed the 1:1 activities for Resident #1 on 4/26/26, 5/9/26 and 5/24/26. She said on 4/26/26 she provided the Resident a hot chocolate during the morning coffee cart, on 5/9/26 the Resident was sleeping and on 5/24/26 the Resident was sleeping. Review of the 1:1 activities form also indicated Resident #1 was seen on 4/29/26 (sleeping), 5/13/26 ( doing ok) and 5/25/26 (talked about breakfast). During an interview on 5/28/26 at 11:55 A.M., Resident #1 thanked the surveyor for coming by again and added he/she did not have a lot of people to talk to because no one comes to visit. He/she said in addition to music, he/she enjoyed watching old westerns and was happy there was currently one on the TV. During an interview on 5/28/26 at 1:13 P.M., the Administrator said the Activity Director had recently started a project to work on providing 1:1 activity visits to residents who did not attend activities. He said they would have to review how the visits are occurring if the Resident was sleeping for three out of six visits in the month.

Based on interviews and record review, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#1) with major depressive disorder, out of a total sample of 18 residents. Specifically, the facility failed to develop, implement, and update the plan of care including following the discontinuation of one to one (1:1) psychotherapy services at the facility for Resident #1 with a history of self-harm, suicide attempts and multiple psychiatric hospitalizations. Findings include:Resident #1 was admitted to the facility in [DATE] with a diagnosis of major depressive disorder, severe with psychotic features following a five-month inpatient psychiatric hospitalization. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating a moderate cognitive impairment. Review of the hospital discharge summary indicated Resident #1 had developed self-injurious behavior of hitting his/herself with their fist to the degree that he/she fractured his/her maxillary sinus. The hospital discharge summary indicated the Resident still got nervous when he/she was all by themselves with worrisome thoughts but understood that hurting him/herself was not the answer. The discharge summary indicated that the Resident had approximately 14 psychiatric hospitalizations in 10 years. Review of the PASRR level II Evaluation Determination, dated [DATE], indicated Resident #1 had a serious mental illness with a history of multiple inpatient psychiatric hospitalizations and a history of suicide attempts by overdose, cutting wrists, walking in front of a moving vehicle, ingesting poison and taping fists/punching self. The evaluation indicated due to a history of behavioral concerns the Resident would require and benefit from behaviorally based treatment plans/interventions. Review of Resident #1's care plans indicated the Resident had a Level II PASRR in place which expired on [DATE] with interventions for 1:1 therapy. As of [DATE], no updated information was reflected on the care plan following a subsequent PASRR review on [DATE], nine months prior. Review of the care plans included information regarding Resident #1 taking psychotropic medications with interventions to administer medications as ordered, monitor behaviors and monitor medication side effects. The care plans did not reflect personalized interventions for Resident #1's history of suicide attempts and psychiatric hospitalizations. Review of the medical record indicated Resident #1 received 1:1 psychotherapy which indicated but was not limited to:[DATE]: therapist notes I will see him again, but if {he/she} reports no significant anxiety again, I will start seeing {him/her} as needed but no longer for ongoing psychotherapy. The surveyor requested all subsequent 1:1 psychotherapy visits from the facility and no additional visits were provided. Review of the consultant psychiatric Nurse Practitioner (NP) notes indicated the following:[DATE]: continues to lack motivation and insight, needs encouragement and support and was responding well to 1:1 therapy; discussed psychotherapist retiring and a new therapist coming. During an interview on [DATE] at 3:05 P.M., the Assistant Director of Nurses (ADON) said the 1:1 psychotherapist retired at the beginning of the year, there was not another psychotherapist and the psychiatric NP was not providing therapy to residents, only medication management. During an interview on [DATE] at 3:17 P.M., the Administrator said the previous 1:1 psychotherapist retired and he was not sure if there was a hand-off to the facility staff on what the plan was for residents who needed 1:1 psychotherapy. He said as far as he knew, no attempts had been made for coordination of services outside of the facility. He said the previous Social Worker may know as they had coordinated with psychiatric services. During an interview on [DATE] at 3:20 P.M., the previous Social Worker said he had left the facility a couple of weeks prior to survey. He said the previous 1:1 psychotherapist had retired at the beginning of the year, and the facility had attempted to get another psychotherapist for individual counseling but had not as of when he had left. He said there were about 12 residents at the facility who were in need of individual psychotherapy and Resident #1 was one of the residents. He said he had not coordinated any additional attempts for psychotherapy for Resident #1. He said he could not remember much about Resident #1's history and could not provide more information. He said the process was for Social Service to complete a history upon admission in the evaluation section of the electronic medical record and then write notes on the Resident's status quarterly. He said if there was a psychiatric history it should be reflected on the care plans. Review of the electronic and paper record failed to include a psychosocial history or assessment. Review of the Social Service progress notes indicated the first Social Work note for Resident #1 was written on [DATE], six months after admission. Review of the Social Service Progress Note, dated [DATE], indicated Resident #1 had a blunted affect, glum mood and was socially withdrawn. The note indicated behavioral health concerns included persistent depressive symptoms, post-traumatic stress disorder and generalized anxiety for which the Resident continued psychotherapy. The note indicated staff were to ensure ongoing engagement with psychiatric care. Current care plan, psychotropic regimen, and monitoring will continue. During an interview on [DATE] at 5:00 P.M., the ADON said she did not know Resident #1 had a history of self-harm. During an interview on [DATE] at 5:10 P.M., Nurse #4 said he regularly works at the facility on the unit with Resident #1. He said the Resident did not talk much and kept to him/herself. He said he did not know about Resident #1's history of self-harm. During an interview on [DATE] at 7:48 A.M., Nurse #3 said he regularly works at the facility on the unit with Resident #1. He said he did not know anything about Resident #1 having a history of suicide attempts or self-harming behavior. During an interview on [DATE] at 10:43 A.M., the Psychiatric NP said she sees residents at the facility for psychotropic medication management and does not see residents for 1:1 psychotherapy. She said Resident #1 was frail both in terms of mood and medical. She said the Resident benefitted from 1:1 psychotherapy because it was good to have social engagement. She said she was not sure if psychotherapy terminated because it was no longer needed or because the therapist was leaving. During an interview on [DATE] at 11:55 A.M., Resident #1 said he/she previously was seeing a psychotherapist and added the dancing doctor. The Resident said he/she liked to talk to him and found it helpful. During an interview on [DATE] at 2:51 P.M., the legal guardian for Resident #1 said the Resident had a significant psychiatric history including self-harm and he expects the Resident to be receiving 1:1 psychotherapy in addition to medication management.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with acceptable standards for one Resident (#11), out of a total sample of 18 residents. Specifically, the facility failed to ensure Resident #11's two prescribed creams were stored securely to avoid potential wrong application. Findings include: Review of the facility's policy titled Self-Administration of Medications, undated, indicated but was not limited to the following:-The facility stores all drugs and biologicals in a safe, secure, and orderly manner.-Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.- Drugs that have missing, incomplete, improper. or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Resident #11 was admitted to the facility in June 2020 with diagnoses which included quadriplegia, cord compression, reduced mobility, and need for assistance for personal care. Review of the Minimum Data Set (MDS) assessment, dated 4/21/2026, indicated Resident #11 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident was moderately cognitively impaired. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following:-Regarding scrotal pain, patient said he/she occasionally gets pain from urinary tract infections (UTI). Nursing has been applying numbing cream to the area to help with pain management. However, the wrong cream was applied and had to be washed off as it caused a burning pain. Review of Physician's Orders indicated:-Supra pubic catheter 18 French with 10 cc balloon to straight drainage for neurogenic bladder, initiated 5/27/24;-Mupirocin external ointment 2% (antibiotic cream). Apply to scrotum topically every dayshift for wound care, initiated 11/26/25 and discontinued 5/1/26;-Mupirocin external ointment 2%. Apply to scrotum topically every evening shift for scrotum care, initiated 11/26/25 and discontinued 5/1/26;-Zostrix cream 0.025% (capsaicin- topical pain relief cream) Apply to per additional directions topically three times a day for pain, date initiated 1/28/26 and discontinued 4/29/26;-House barrier cream to coccyx every shift, initiated 11/8/22;-Bio freeze External gel 4% (menthol topical analgesic) Apply to shoulder/back/knee topically every 4 hours for pain, initiated 11/03/25;-Nystatin-Triamcinolone cream 10000-0.1-unit gm. Apply to inner thighs bilaterally topically two times a day for rash. Initiated 12/3/25;-Diclofenac sodium external gel 15 (diclofenac sodium topical). Apply to right hand/right wrist topically 2 times a day for pain, initiated 11/4/25;-Diclofenac sodium external gel 15 (diclofenac sodium topical). Apply to right knee topically every 6 hours as needed for pain, initiated 11/25/25. During an interview on 5/28/26 at 11:59 A.M., Resident #11 said on one occasion Certified Nursing Assistant (CNA) #4 took the wrong cream from his/her top drawer and put it on his/her genital area. Resident #11 said he/she does not know which cream was applied, just that it was the wrong cream because it burned. On 5/28/26 at 12:04 P.M., the surveyor, with Resident #11's permission, observed in the top drawer of the dresser:-Four tubes of barrier cream (two with blue caps, one with orange cap, one with pink cap) inside a grey bucket,-One tube Mupirocin 2% ointment, and one tube of white cap hydrophilic wound dressing lining in the drawer; and-On the bedside table there was one tube of Capsaicin cream 0.025% During an interview on 5/28/26 at 3:06 P.M., CNA #4 said she does not remember putting the wrong cream on Resident #11 in January 2026. During an interview on 5/28/26 at 3:20 P.M., Nurse #7 observed with the surveyor the Mupirocin 2% ointment in the top drawer with the four barrier creams and one tube of hydrophilic wound dressing cream and the Capsaicin cream 0.025% on the bedside table. Nurse #7 said the Mupirocin 2% ointment and the Capsaicin cream 0.025% should be stored in the locked nursing cart. During an interview on 5/28/26 at 3:29 P.M., Resident #11 said CNA #4 only put the wrong cream once on his/her genital area. Resident #11 said, It burned and felt like it was going to melt my diaper. During an interview on 5/28/26 at 3:38 P.M., the Director of Nursing said all prescribed creams should be kept in the locked treatment carts.

Based on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations and ensure this information was part of the medical record for two Residents (#9 and #46), out of a total sample of 18 residents. Findings include:Review of the facility's notice titled Notice of Nursing Facility Residents' Rights Regarding a Transfer or Discharge, undated, indicated but was not limited to the following:-You may be transferred or discharged only for one or more of the following reasons:1.Transfer is necessary for the Resident's welfare and the Resident's needs cannot be met by the Facility-In general, you cannot be transferred/discharged until thirty (30) days after you receive the nursing facility's notice of transfer/discharge, unless you agree to an earlier date. However, the nursing facility reserves the right to issue a Notice of Intent to Transfer/Discharge with Less than Thirty (30) Days' Notice as long as the reason(s) listed in the notice are applicable to the reasons listed above. Review of the facility's policy titled Bed-Holds and Returns, undated, indicated but was not limited to the following:-All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). A. Resident #9 was admitted to the facility in July 2024 with diagnoses including dysphagia (trouble swallowing) following a cerebral infarction (a stroke) and vascular dementia. Review of the Minimum Data Set (MDS) assessment for Resident #9, dated 2/25/2026, indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Review of the medical record for Resident #9 indicated he/she was transferred to the hospital for evaluation in February and May 2026. The medical record, including both electronic and paper, failed to indicate notice of transfer and bed hold documents were provided to the Resident and/or his/her representative prior to the transfer as required. During an interview on 5/28/2026 at 3:28 P.M., Nurse #8 said when a resident is transferred to the hospital for an evaluation, they send a list of medications, a copy of the Advance Directives, active orders, demographics sheet, Notice to Transfer form, and Bed Hold Policy form. Nurse #8 said they also take a copy of the Notice to Transfer and Bed Hold Policy forms and keep them in the residents' paper chart. Nurse #8 said if the copy of the form is not in the paper chart, she is not sure where else it would be located, but that is where it should be. B. Resident #46 was admitted to the facility in October 2015 with diagnoses including adult failure to thrive, vascular dementia, and dislocation of internal left hip prosthesis. Review of the MDS assessment for Resident #46, dated 4/14/2026, indicated the Resident was severely cognitively impaired, as evidenced by a BIMS score of 3 out of 15. Review of the medical record for Resident #46 indicated he/she was transferred to the hospital for evaluation once in February 2026, twice in March 2026, and twice in May 2026. The medical record, failed to indicate notice of transfer and bed hold documents were provided to the Resident and/or his/her representative prior to the transfer as required for the transfers in February 2026, one of the two transfers in March 2026, and both transfers in May 2026. During an interview on 6/1/2026 at 10:40 A.M., Nurse #2 said when a resident is being transferred to the hospital, it is the responsibility of the nurse to fill out the Notice of Transfer and Bed Hold Policy forms. Nurse #2 said one copy of the forms is sent with the resident and another copy is kept in the resident's paper chart. During an interview on 6/1/2026 at 10:45 A.M., the Assistant Director of Nursing (ADON) said there are packets located at the nurses' station on each unit that contain a checklist as well as the forms that are required to be completed by the nurse when a resident is being sent to the hospital. The ADON said these packets include the Notice of Transfer and Bed Hold Policy forms. The ADON said the process is that the nurse completes these forms with the resident and/or their representative, sends one copy with the resident to the hospital, and a second copy is kept in the resident's paper chart. The ADON said these forms should be completed for every hospital transfer. During an interview on 6/1/2026 at 1:18 P.M., the Director of Nursing (DON) said it is her expectation is that Notice of Transfer and Bed Hold Policy forms are completed for each resident hospital transfer. She said one copy should be sent with the resident and a second copy should be kept in the resident's paper chart.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of two Residents (#13 and #1), out of a sample of 18 residents. Specifically, the facility:1. Failed for Resident #13 to ensure an MDS was accurately coded for a significant weight gain not prescribed by the physician; and2. Entered a diagnosis of schizoaffective disorder for Resident #1 on four MDSs without documentation of a physician detailed evaluation as indicated in the Resident Assessment Instrument (RAI) Manual. Findings include: 1. Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2025, indicated but was not limited to the following: Section K0310 -Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. -Code 1, yes on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was planned and pursuant to a physician's order. -In cases where a resident has a weight gain of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan, K0310 can be coded as 1. -Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician. -To code K0310 as 1, yes, the expressed goal of the weight gain diet must be documented. Resident #13 was admitted to the facility in December 2025 with diagnoses including Congestive Heart Failure (CHF), Acute Kidney Failure and Type 1 diabetes. Review of Resident #13's medical record indicated Resident #13 sustained a weight loss of 19% since admission, and a weight gain of 5% or more in 30 days. Further review of Resident #13's medical record failed to indicate the weight gain was prescribed by a physician. Review of the MDS assessment, dated 3/24/26, indicated but was not limited to the following: -Section K- Swallowing/Nutritional Status K0300 Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months. -Coded: 2 - Yes, not on a physician-prescribed weight-loss regimen. K0310. Weight Gain: Gain of 5% or more in the last month or gain of 10% or more in last 6 months. -Coded: 1 - Yes, on physician-prescribed weight-gain regimen. During an interview on 6/1/26 at 12:47 P.M., the Registered Dietitian said she completes section K on the MDS. She said Resident #13 is not on a prescribed weight gain program, she coded the MDS in error. She said it is very difficult to determine if Resident #13 has had an actual weight gain or loss with the weights that are documented in the medical record, and the goal is for the Resident's weight to become stable. 2. Resident #1 was admitted to the facility in May 2025 with a diagnosis of major depressive disorder and was receiving antipsychotic medication. Review of the MDS assessment, dated 8/6/25, indicated Resident #1 did not have a diagnosis of schizophrenia (e.g., schizoaffective and schizophreniform disorders). Review of subsequent MDSs, dated 11/4/25, 2/5/26, 3/3/26 and 5/13/26, indicated Resident #1 had a diagnosis of schizophrenia. Review of the electronic medical record list of diagnoses indicated a diagnosis of schizoaffective disorder was added in November 2025. Review of the medical record including psychiatric consultant services, two medical hospitalizations, the Department of Mental Health (DMH) Pre-admission Screening and Resident Review (PASRR) level II evaluation, and physician progress notes failed to include an evaluation to indicate the determination for a new diagnosis of schizophrenia. During an interview on 5/28/26 at 9:43 A.M., the MDS Coordinator said she could not locate supporting documentation of an evaluation for schizoaffective disorder and was not sure about coding the diagnosis on the MDS according to the RAI Manual. During an interview on 5/28/26 at 12:11 P.M., the Regional Director of Reimbursement said the MDS Coordinator was new to the MDS role and was unfamiliar with coding schizophrenia on an MDS. She said the MDS coordinator had been educated that any medication needed an appropriate diagnosis and because Resident #1 was previously on an antipsychotic the physician was contacted to add the schizoaffective diagnosis. She said they had reviewed the clinical documentation for Resident #1 and there was no supporting documentation for a diagnosis of schizoaffective disorder.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was readmitted to the Facility after a hospitalization and who required follow up appointments one week post discharge with Cardiology and Gastrointestinal providers, the Facility failed to ensure he/she was provided services that met professional standards of practice when arraignments for the follow-up appointments were not made or scheduled by nursing.Findings Include:Resident #1 was admitted to the Facility in October 2025, diagnoses included gastrointestinal hemorrhage, anemia, atrial fibrillation (irregular heartbeat), hypertension, anoxic brain damage, and seizure disorder. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 was hospitalized for Upper Gastrointestinal (GI) Bleed and was noted with a new onset of Atrial Fibrillation with Rapid Ventricular Response (RVR). The Summary further indicated that Resident #1's discharge instructions included the following: - Upper Gastrointestinal (GI) Bleed; follow up with Gastrointestinal within one week-Atrial Fibrillation with RVR; follow up with Cardiology within one weekDuring an interview on 12/29/25 at 1:48 P.M., Family Member #1 said Resident #1 was supposed to have follow-up appointments with a Cardiologist and Gastroenterologist within one week after his/her discharge from the hospital. Family Member #1 said the Facility did not schedule Resident #1's follow-up appointments within a week and said after he/she was discharged from the Facility (after being readmitted for two weeks) the staff at his/her residential home made the appointments for him/her.During an interview on 01/05/26 at 11:40 A.M., the Unit Manager said on 10/22/25 she worked on the dayshift and reviewed Resident #1's Hospital Discharge Summary upon his/her readmission to the Facility. The Unit Manager said she verified Resident #1's orders with the Physician but could not recall seeing the Summary's instructions for follow-up appointments and that she must have missed them.Review of Resident #1's Physician Interim/Telephone Orders, dated 10/24/25, (written by the Nurse Practitioner) indicated to schedule follow-up with Cardiology and Gastrointestinal (GI).During an interview on 01/05/26 at 12:34 P.M., the Nurse Practitioner (NP) said she saw Resident #1 on 10/24/25 for a follow-up hospital readmission (two days after his/her readmission). The NP said that follow up appointments are sometimes scheduled by the hospital but Resident #1's had not been. The NP said on 10/24/25 she wrote an order for Resident #1 to follow up with Cardiology and GI, flagged the order in his/her chart and said she told the nurse (exact name unknown) who was assigned to Resident #1, there were new orders.During an interview on 12/30/25 at 2:41 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 10/24/25 and was assigned to Resident #1. Nurse #1 said she was not aware and had not seen that Resident #1 had orders for follow-up appointments with Cardiology and GI.Review of Resident #1's medical record indicated there was no documentation to support that follow-up appointments with Cardiology and Gastrointestinal had been scheduled, per his/her Hospital Discharge Summary instructions.During an in-person interview on 12/30/25 at 4:08 P.M. and a telephone interview on 01/07/26 at 11:02 A.M., the Director of Nursing (DON) said she was not aware that Resident #1 was supposed to have follow-up appointments with Cardiology and GI. The DON said she was not sure if Resident #1's follow-up appointments were made, and that she would have to look in the Appointment Book on the unit.The DON reviewed the Appointment Book from the East Unit during the interview and said there were no follow-up appointments scheduled for Resident #1 during his/her readmission.The DON said it is her expectation that nurses fully review residents' hospital discharge summaries, follow the Facility's process and not miss any orders for follow-up appointments.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Agent (HCA, Family Member #1) was very involved in his/her care, the Facility failed to ensure staff promptly notified Family Member #1 of a change in Resident #1's status, when on 04/25/25, he/she fell while working with Occupational Therapy (OT). Findings include: Review of the Facility Policy titled Change in a Resident's Condition or Status, undated, indicated that the Facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Resident #1 was admitted to the Facility in April 2025 diagnoses included status-post left below the knee (BKA) amputation, peripheral vascular disease, urinary retention with an indwelling urinary catheter (a tube inserted into the bladder allowing urine to flow out of the body) in place, diabetes mellitus, and depression. Review of Resident #1's Durable Power of Attorney (POA), dated 03/14/25, indicated his/her HCA's (Family Member #1) contact information was listed and available for staff. Review of Resident #1's Consent to Treat Form, dated 04/09/25, indicated he/she requested, and his/her HCA (Family Member #1) signed the form. Review of Resident #1's Side Rail Consent, dated 04/09/25, indicated he/she requested and his/her HCA (Family Member #1) signed the form. Review of Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 04/10/25, indicated his/her HCA (Family Member #1) signed as his/her legal representative. During a telephone interview on 05/13/25 at 11:11 A.M., Family Member #1 (HCA) said Facility staff were well aware of how involved she was with Resident #1's care. Family Member #1 (HCA) said the Facility allowed her to sign a portion of Resident #1's admission paperwork, including the Consent to Treat and his/her MOLST. Family Member #1 (HCA) said that she would visit Resident #1 daily for hours at a time, and was always available. Family Member #1 (HCA) said that no one from the Facility called her on 4/25/25 to inform her of Resident #1's fall, that Resident #1 was the one who informed her. During a telephone interview on 05/14/25 at 1:06 P.M., Resident #1 said he/she refers to his/her HCA (Family Member #1) for everything and would have wanted her to know about the fall. During a telephone interview on 05/19/25 at 12:51 P.M., Nurse #1 said that on 04/25/25, Resident #1 was on her assignment and said she had completed the facility incident report after his/her fall. Nurse #1 said that she was unable to located a phone number for Resident #1's HCA on his/her Face Sheet and asked Resident #1 if there was anyone that he/she wanted her to call following the fall. Nurse #1 said that if Resident #1's HCA information had been on his/her Face Sheet, she would have called to notify them of his/her fall because that is protocol. During an interview on 05/14 at 3:13 P.M., the Director of Nurses (DON) said that he was unaware that Resident #1's HCA was not notified of the incident that had occurred with OT on 04/25/25. The DON said that it is the Facility's expectation that nursing notify a resident's HCA or responsible party with any fall unless the resident is against such notification.

Based on records reviewed and interviews for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, that nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs. Findings include: Review of the Facility Policy titled Baseline Care Plans, dated as last revised 07/26/17, indicated a Baseline Care Plan will be developed and implemented within 48 hours of admission, for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The Policy indicated that the baseline care plan will include the minimal healthcare information necessary to properly care for a resident including but not limited to; -Initial goals based on admission orders; -Physician Orders; -Dietary Orders; -Therapy Services; -Social Services; and Preadmission Screening and Resident Review (PASRR) recommendations, if applicable. The Policy further indicated that the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop a comprehensive interdisciplinary care plan. Resident #1 was admitted to the Facility in April 2025, diagnoses included status-post left below the knee (BKA) amputation, peripheral vascular disease, urinary retention with an indwelling urinary catheter (a tube inserted into the bladder to allow urine to flow out of the body) in place, diabetes mellitus, and depression. Review of Resident #1's Hospital Discharge Summary, dated 02/04/25, indicated his/her immediate care needs were identified as followed; -New surgical wound to left below the knee amputation site; -Urinary retention with an indwelling catheter in place; -Psychotropic medications in use; -Diabetes Mellitus and impaired skin with nutrition needs; and -Anticoagulation therapy. Review of Resident #1's Medical Record indicated there was no documentation to support that Baseline Care Plans were developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission. Review of Resident #1's Medical Record, indicated that nursing had not initiated, developed, or implemented necessary care plans for his/her surgical wound, indwelling urinary catheter, psychotropic medication use, diabetic needs, and anticoagulation therapy until 04/21/25 (12 days after admission). During an interview on 05/14/25 at 12:13 A.M., Nurse #3 said that the nurse responsible for the resident's admission is expected to begin the Baseline Care Plans for that resident and if unable to complete the baseline care plans at that time, the responsibility would get passed on to the next shift until it is completed. During a telephone interview on 05/19/25 at 12:03 P.M., the Nurse Clinical Manager said that she was not aware that Resident #1's baseline care plans had not been completed within 48 hours and said she was not certain as to who was responsible for completing the resident's baseline care plan. During an interview on 05/14/25 at 3:13 P.M., the Director of Nurses (DON) said that he was not aware that Resident #1's baseline care plans had not been completed upon admission. The DON said that it is the Facility's expectation that all residents have a complete baseline care plan in place within 48 hours after admission that allows the staff to provide care and services that each resident requires.

Based on records reviewed and interviews for one of three sampled residents (Resident # 1), who upon admission required a therapeutic diet in relation to diabetes mellitus, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals, and outcomes that addressed his/her person-centered nutritional needs. Findings include: Review of the Facility Policy titled Comprehensive Care Plans, dated a last revised 07/2023, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, emotional and psychological needs is developed for each resident within seven days of the completion of the resident's comprehensive assessment. The Policy further indicated that identifying problem areas and their causes and developing interventions that are targeted and meaningful to the residents are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. Resident #1 was admitted to the Facility in April 2025 diagnoses included status-post left below the knee (BKA) amputation, peripheral vascular disease, urinary retention with an indwelling urinary catheter (a tube inserted into the bladder to allow urine to flow out of the body) in place, diabetes mellitus (insulin dependent), and depression. Review of Resident #1's Hospital Discharge Summary, dated 04/09/25, indicated his/her diet, according to the International Dysphagia Diet Standardization Initiative (IDDSI, framework that provides a standardized way to describe food and drink textures for people with swallowing difficulties) was IDDSI Level Six (6, known as a soft bite size with supervision dysphagia diet). Review of Resident #1's Admission Nutritional Evaluation, dated 04/14/25, indicated his/her diet was Low Calorie Sweetener (LCS), two (2) gram (g) sodium (Na), puree (blended or mashed until smooth) textures and nectar (a type of thickened liquid consistency of fruit nectars) liquids while also providing a P.M. diabetic snack. Review of Resident #1's Medical Record from 04/09/25 through 04/30/25, there is no documentation to support a Nutritional Care Plan had been developed and implemented that was person-centered to meet his/her nutritional needs. During a telephone interview on 05/15/25, the Registered Dietician (RD) said that he was not aware Resident #1 did not have a Nutritional Care Plan in place and said he is not always able to get a care plan in for all of the residents. The RD said it was his responsibility as part of the Interdisciplinary Team (IDT) to develop a nutritional care plan. During an interview on 05/14/25 at 3:13 P.M., the Director of Nurses (DON) said that he was not aware that Resident #1 did not have a Nutritional Care Plan in place. The DON said it is the Facility's expectation that the IDT to work together and ensure all care plans, including nutrition (if needed) are person-center and in place at the time the comprehensive care plan is completed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had been assessed as requiring nutritional interventions for wound care, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when recommendations made by the Registered Dietician (RD) for Resident #1, were not followed up on timely by nursing. Findings include: Review of the Policy titled Consultants, undated, indicated the Facility utilizes outside resources to furnish specific services provided by the facility. The Policy further indicated Consultants provide the Administrator with written, dated, and signed reports for each consultation visit. Such reports contain the consultants; -Recommendations; -Plans for implementation of his/her recommendations; -Findings; and -Plans for continued assessment. Resident #1 was admitted to the Facility in April 2025 diagnoses included status-post left below the knee (BKA) amputation, peripheral vascular disease, urinary retention with an indwelling urinary catheter (a tube inserted into the bladder to allow urine to flow out of the body) in place, diabetes mellitus, and depression. Review of Resident #1's Admission Nutritional Evaluation, dated 04/14/25, indicated he/she was admitted with a new surgical wound related to his/her left below the knee amputation (BKA). The Evaluation further indicated that the Registered Dietician (RD) recommended to start a Multivitamin (MVI), add 30 milliliters (ml) of liquid protein, and add yogurt to breakfast. Review of Resident #1's Physician's Orders, dated 04/15/25, indicated to add yogurt daily to his/her breakfast. Review of Resident #1's Wound Monitoring Dietician Note, dated 04/28/25, indicated the RD again recommended to begin a MVI and add 30 ml of liquid protein to support wound healing. Review of Resident #1's Medical Record, from 04/14/25 through 04/30/25, indicated that there was no documentation to support that his/her physician had been notified of the RD recommendations on 04/14/25 or 04/28/25 regarding the addition of a MVI and 30 ml of liquid protein. During a telephone interview on 05/19/25 at 12:03 P.M., the Nurse Clinical Manager said she was unaware that RD recommendations had not been communicated to Resident #1's physician. The Nurse Clinical Manager said that the RD (or any consultant) is to electronically mail (e-mail) the Director of Nurses (DON) their recommendations and the DON will then distribute the recommendations to the appropriate staff to review with the resident's physician to obtain orders as appropriate. During a telephone interview on 05/15/25 at 2:48 P.M., the Registered Dietician (RD) said he did not know the recommendations that he made for Resident #1 on 04/14/25 and 04/28/25, had never been followed up on. The RD said that at the end of the day after being in the Facility, he uploads his recommendations into a portal (used to communicate with the Facility), runs a report that includes any recommendations made, and e-mails the report to the DON. The RD said once the DON receives the report, the DON distributes his recommendation to the appropriate staff (dietary/nurse) to review with the resident's physician and obtain a physician order if agreeable. During an interview on 05/14/25 at 3:13 P.M., the DON said he was not aware Resident #1's nutritional recommendations from the RD had never been addressed. The DON said that it is the Facility's expectation that all recommendations from any provider, including nutrition, are to be sent to me by e-mail and then are given to the nurses on the unit attending to the resident and promptly followed up with the resident provider and obtained an order if approved.

Based on interviews and observations, the facility failed to ensure grievance forms were available in resident care and public areas so residents and/or visitors were able to access forms without requesting staff assistance. Findings include: Review of the facility's policy titled Grievance, dated as last revised 3/2024, indicated but was not limited to the following: - The resident and/or resident representative will be made aware of the right to voice grievances, orally in writing and anonymously. - The resident will be made aware of the right to voice grievances to other agencies and entities in addition to the facility without fear of discrimination or reprisal. - The Administrator is identified as the Grievance Official responsible for oversight of the grievance process in the facility. - The Administrator will ensure that confidentiality is maintained, to the extend possible, any information regarding any grievances submitted anonymously. - If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance/Complaint Report Form. During the Resident Group Meeting on 3/4/25 at 1:00 P.M., six out of six residents said they were unaware of how to file a grievance outside of concerns presented at the monthly Resident Council Meetings. On 3/4/25 at 2:50 P.M., the surveyor observed the East Unit resident care area. There were no grievance forms observed on the unit. On 3/4/25 at 3:00 P.M., the surveyor observed the [NAME] Unit resident care area. There were no grievance forms observed on the unit. On 3/4/25 at 3:10 P.M., the surveyor observed the main entrance area. There were no grievance forms observed in the public area. On 3/4/25 at 3:12 P.M., the surveyor observed the hallway entrance to the East Unit resident care area. Posted in a display case was a notice which indicated Grievance Forms are available at each nursing station. During an interview and observation on 3/6/25 at 11:05 A.M., the Director of Social Services said grievance forms were located on each resident care unit and the Administrator was the Grievance Officer. The Director of Social Services said typically the resident would request a grievance form from a staff member, fill out the grievance and give the form to one of the staff nurses. The Director of Social Services said the nurse would give the grievance to him and he'd review the grievance/concern before passing it on the Grievance Officer. The surveyor asked the Director of Social Services to locate the grievance forms on the East Unit resident care area. The Director of Social Services was unable to locate any grievance forms on the resident care unit and said he believed there was a wall folder with forms but the wall folder was gone. During an interview on 3/6/25 at 11:15 A.M., Nurse #2 said the Grievance forms were kept at the nurses' station and residents/family would request a form from any staff. Nurse #2 said the form would be returned to a staff and then given to the evening supervisor or Administrator for review. The surveyor asked Nurse #2 to locate the Grievance forms on the [NAME] Unit resident care area. Nurse #2 was unable to locate any grievance forms on the resident care unit. During an interview on 3/6/25 at 11:23 A.M., the Administrator was made aware of the concerns expressed during the Resident Group Interview and the lack of availability of grievance forms throughout the facility. The Administrator said grievance forms should be readily available to residents/family representatives and should be able to be filed anonymously.

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for nine Residents (#59, #67 #18, #24, #27, #31, #64, #68, #77 and #2 ), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #59, Urology consultation progress notes/office visit notes were part of the medical record; 2. For Residents #18, # 24, #27, #31, #64, #68, and #77, the Medication Administration Record (MAR) was accurate, documenting on 3/4/25 and 3/5/25, the residents received their nutritional supplements when they remained in the refrigerators on their respective units; and 3. For Resident #2, the MAR was accurate, documenting the Resident was being administered off-loading booties when they were not available to the Resident. Findings include: 1. Review of the facility's policy titled Consultants, undated, indicated but was not limited to the following: -Facility uses outside resources to furnish specific services. -Consultants provide the Administrator with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's recommendations, plan for implementation of his/her recommendations, finding, and plan for continued assessments. Resident #59 was admitted to the facility in September 2024 with diagnoses which included neuromuscular dysfunction of the bladder, acute cystitis with hematuria, infection and inflammatory reaction due to indwelling urethral catheter (thin tube inserted into the bladder to drain urine), and urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 2/11/25, indicated he/she had a neurogenic bladder and had an indwelling catheter. Review of the hospital Discharge Summary, dated 9/23/24, indicated but was not limited to the following: -He/she presented to the hospital with a chronic indwelling Foley catheter with scrotal swelling and hematuria. -Sepsis due to catheter associated urinary tract infection (UTI). -Suprapubic tube (SPT) placement (catheter inserted directly into the bladder though abdominal wall to drain urine). -Continue SPT and foley catheter. -Wound check at Urology clinic 1-2 weeks post discharge. -Change SPT every 4 weeks (end of September). -Appointment with Urology scheduled 10/1/24. Review of the nursing and physician progress notes failed to indicate he/she went to Urology on 10/1/24 per discharge summary. Review of the medical records failed to indicate an Appointment or Consultation report for the 10/1/24 appointment. The facility provided an Appointment or Consultation report for a Urology appointment on 10/17/24 indicated SPT and Foley catheters were changed, wound is healing well. Follow up in 5 weeks. The office visit note was not in the medical record. Further review of the nursing and physician progress notes failed to indicate he/she had been to the Urologist or any collaboration of care with the Urologist relating to any recommendations, plan, or follow ups needed from 9/1/24 through 3/6/25. Further review of the medical record failed to indicate any documentation related to subsequent monthly Urology Appointments. Review of the hospital Discharge Summary, dated 11/12/24 indicated but was not limited to the following: -He/she presented with fatigue, fever, and altered mental status. -Has a SPT and foley catheter, admitted in septic shock. -Will complete 10 days of appropriate antibiotics considering complicated UTI. -Follow-up with Urology as scheduled next week for SPT change and possible removal of Foley catheter. The Surveyor requested all visit notes and was advised there were none. The only document pertaining to a Urology Appointment was the one-page referral from 10/17/24. The surveyor asked when the Foley catheter was removed and Consulting Staff#2 could not provide the information from the medical record. The surveyor was unable to interview Nurse #1 regarding the Urology notes, plan of care and coordination of care, as she was agency, and had never been to the facility before. Additionally, the Clinical Nurse on the day shift, the Director of Nurses (DON), and the Assistant Director of Nurses (ADON) were not available for interview. During an interview on 3/6/25 at 1:56 P.M., Consulting Staff #2 said the 10/17/24 referral note is the only Urology consultation note in the medical record to date and could not provide any documentation regarding other visits and coordination of care. She said the facility sends a referral to the appointment, but they don't always get it back, and it is up to the resident to request the visit note. She said the Urology Office advised her Resident #59 would need to sign a medical record release for their medical record department to forward all visit notes October 2024-present. On 3/6/25 at 5:10 P.M., the Administrator requested and received the Urology notes from the Urology Office. Review of the Urology Appointment records indicated but were not limited to the following: -10/17/24: Both SPT and Foley catheter were removed and replaced; follow up in one month; if penoscrotal wound is appropriately healed on follow up will likely remove Foley catheter and transition to just SPT. -11/21/24: Unfortunately, on 11/7/24 patient was admitted to the hospital for septic shock for likely UTI, treated with IV antibiotics and is fully recovered. Wound looks well healed. Both catheters were removed and Foley catheter not replaced, SPT replaced; follow up in one month -2/6/25: Patient presented for SPT change; SPT removed and replaced; Return 3/6/25. -3/6/25: Patient presented for SPT change; SPT removed and replaced; Return 4/3/25. There was no note for a visit on/around 12/21/24 and Resident was admitted to the hospital 1/5/25-1/16/25 unrelated to catheter. During an interview on 3/6/25 at 5:10 P.M., Consulting Staff #2 said they try to call for visit notes, or sometimes the office will call with recommendations, but there is not a formal process to ensure the facility receives consultation recommendations and/or visit notes to ensure no recommendations are missed and to file in the medical record. 41106 2A. Resident #18 was admitted to the facility in October 2015. Review of the Minimum Data Set (MDS) assessment, dated 2/4/25, indicated Resident #18 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. On 3/4/25 at 4:01 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #18's Nutritional treat, frozen labeled (2 PM) and dated 3/4/25- lunch tray. On 3/5/25 at 4:19 P.M., the surveyor observed Resident #18's Nutritional treat, frozen labeled (2 PM) dated 3/5/25- lunch tray, in the resident refrigerator on the unit. Review of the Medication Administration Record (MAR) indicated Resident #18 received the nutritional treat, frozen (2 PM) dated 3/4/25 and 3/5/25 at 2:00 P.M. B. Resident #24 was admitted to the facility in August 2019. Review of the MDS assessment, dated 1/9/25, indicated Resident #24 Resident is rarely/never understood. On 3/4/25 at 12:39 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #24's Ready care shake labeled (10:00 AM) dated 3/4/25- breakfast tray On 3/4/25 at 4:01 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #24's Ready care shake labeled (10:00 AM) dated 3/4/25- breakfast tray. On 3/5/25 at 11:49 A.M., in the resident refrigerator on the unit, the surveyor observed Resident #24's Ready care shake labeled (10:00 AM) dated 3/5/25- breakfast tray. On 3/5/25 at 4:19 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #24's Ready care shake labeled (10:00 AM) dated 3/5/25- breakfast tray and Ready care shake (2:00 PM) dated 3/5/25- lunch tray. Review of the MAR indicated Resident #24 on 3/4/25 and 3/5/25 received Ready Care Shake Supplements at 9:00 A.M., and 1:00 P.M., and consumed 100% of them. C. Resident #27 was admitted to the facility in April 2021. Review of the MDS assessment, dated 1/14/25, indicated Resident #27 scored 3 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. On 3/4/25 at 4:01 P.M., in the resident refrigerator on the unit, the surveyor observed Resident # 27's Ready care shake labeled (10:00 AM) dated 3/4/25- breakfast tray and Ready care shake labeled (2:00 PM) dated 3/4/25- lunch tray, and a super pudding labeled ready shake labeled (2:00 PM) in the resident refrigerator on the unit. On 3/5/25 at 4:19 P.M., in the resident refrigerator on the unit, the surveyor observed Resident # 27's Ready care shake labeled (10:00 AM) dated 3/5/25- breakfast tray and Ready Care shake in the resident refrigerator on the unit (2:00 PM) dated 3/5/25- lunch tray. Review of the MAR indicated Resident #27 on 3/4/25 and 3/5/25 received Ready Care Shake Supplements at 8:00 A.M., and 12:00 P.M. D. Resident #31 was admitted to the facility in November 2017. Review of the MDS assessment, dated 12/5/25, indicated Resident #31 scored 8 out of 15 on the BIMS, indicating he/she had moderate cognitive impairment. On 3/5/25 at 4:22 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #31's Nutritional treat, frozen labeled (2 PM) dated 3/5/25-lunch tray. Review of the MAR indicated Resident #31 on 3/5/25 received Frozen Nutritional Treat at 8:00 A.M. E. Resident #64 was admitted to the facility in April 2024. Review of the MDS assessment, dated 2/11/25, indicated Resident #64 scored 8 out of 15 on the BIMS, indicating he/she had moderate cognitive impairment. On 3/4/25 at 4:01 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #64's Super pudding labeled (2:00 PM) 3/4/25 lunch tray. On 3/5/25 at 4:19 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #64's Super pudding labeled (2:00 PM) 3/5/25 lunch tray. Review of the MAR did not indicate Resident #64 received super pudding supplement on 3/4/25 or 3/5/25 at 2:00 PM. F. Resident #68 was admitted to the facility in May 2023. Review of the MDS assessment, dated 1/14/25, indicated Resident #68 Resident is rarely/never understood. On 3/5/25 at 4:22 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #68's Ready Care shake labeled (10:00 AM) dated 3/5/25- breakfast tray, Ready Care shake labeled (2:00 PM) dated 3/5/25- lunch tray, and Nutritional treat, frozen labeled (2 PM) dated 3/5/25-lunch tray. Review of the MAR indicated Resident #68 on 3/5/25 received Ready Care Shake Supplements at 8:00 A.M., and 12:00 P.M., and received Magic Cup (Frozen nutritional supplement) at 12:00 P.M. G. Resident #77 was admitted to the facility in December 2024. Review of the MDS assessment, dated 1/2/25, indicated Resident #77 scored 5 out of 15 on the BIMS, indicating he/she had severe cognitive impairment. On 3/4/25 at 4:01 P.M., in the resident refrigerator on the unit, the surveyor observed Resident #77's Nutritional treat, frozen labeled (2 PM) dated 3/4/25-lunch tray. Review of the MAR indicated Resident #77 on 3/4/25 received the Frozen Nutritional Treat at 8:00 A.M., During an interview on 3/6/25 at 8:01 A.M., Nurse #2 said some supplements come up on the residents' tray from the kitchen, other supplements are delivered to the resident refrigerator. Those supplements are supposed to be given out by the nurses mostly at 10:00 A.M. and 2:00 P.M. and signed off on the MAR when given. During an interview on 3/6/25 at 8:05 A.M., Nurse #3 said the supplements are ordered by the doctor and are in the refrigerator. When a nurse gives them to a resident, they sign off on the MAR. During an interview on 3/6/25 at 8:15 A.M., Certified Nursing Assistant (CNA) #1 said the CNAs never give out the supplements like magic cup or shakes that are in the refrigerator. During an interview on 3/6/25 at 8:35 A.M., the Food Service Manager (FSM) said he prints up labels for all the supplements ordered and puts them in the refrigerator in the morning. He said the nurses are responsible for delivering them to the residents. During an interview on 3/6/25 at 9:21 A.M., the Assistant Director of Nurses (ADON) and Corporate Nurse #1 both said the nurses should not be signing off on the MAR the supplements were given and consumed 100% when they are still on the tray in the refrigerator. 3. Resident #2 was admitted to the facility in April 2022 with diagnoses which included: stroke with speech and language deficits, dementia, and protein-calorie malnutrition. Review of the MDS assessment, dated 2/18/25, indicated Resident #2 scored 3 out of 15 on the BIMS indicating he/she had severe cognitive impairment. In addition, Section GG indicates Resident #2 is dependent on rolling right and left, sit to lying and lying to sit. Resident #2 is at risk for pressure ulcers, Resident has one stage 3. Review of Resident #2's Physician's Orders indicated for the Resident to have pressure off-loading boots when in bed, every shift, initiated 1/2/25. Review of Resident #2's MAR for January, February, and March 2025 indicated nursing administered offloading boots while in bed all three shifts every day. On 02/28/25 at 10:20 A.M., Resident #2 observed lying in bed not wearing booties. On 3/04/25 at 9:08 A.M., Resident #2 observed lying in bed not wearing booties. On 3/05/25 at 11:13 A.M., Resident #2 observed lying in bed not wearing booties. On 3/05/25 at 12:35 P.M., Resident #2 observed lying in bed not wearing booties. On 3/06/25 at 3:01 P.M., Resident #2 observed lying in bed not wearing booties. During an interview on 3/05/25 at 5:00 P.M., Certified Nursing Assistant (CNA) #8 said she is not aware of any booties for Resident #2. During an interview on 3/05/25 at 5:02 P.M., CNA #9 said she has never seen booties on Resident #2, and he/she doesn't' have any in his/her room. CNA #9 said she takes care of Resident #2 weekly and has for many months. CNA #9 said she will put a pillow under Resident #2's heels, but never booties. During an interview on 3/05/25 at 4:45 P.M., the Assistant Director of Nurses (ADON) searched Resident #2's room and could not find any booties. The ADON said if Resident #2 doesn't have any booties, the nurses should not be documenting they are putting them on.

Based on record review and interview, the facility failed to ensure a resident at risk for skin breakdown with a wound received necessary treatment and services to promote healing for one Resident (#59), out of a total sample of 18 residents. Specifically, the facility failed to complete weekly skin checks, to investigate wounds caused by injury/trauma, and to follow wound physician's recommendations and accurately implement care and treatment of a non-pressure wound to the Resident's left knee, heel, and shin. Findings include: Review of the facility's policy titled Skin Tears-Care of Abrasions and Minor Breaks, undated indicated but was not limited to the following: -Record the following in the resident's medical record: a. Complete an in-house investigation of the causation. b. Document physician and family notification, and resident education (if completed) in medical record. c. When an abrasion/skin tear/bruise is discovered, complete an investigation to determine causative effect. Review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, undated indicated but was not limited to the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The nurse supervisor/charge nurse and/or the department director or supervisor shall complete an Incident/Accident Form and submit it to the Director of Nurses. -Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Resident #59 was admitted to the facility in September 2024 with diagnoses which included chronic non-pressure ulcer of right lower leg, venous insufficiency, and pressure ulcer stage 3 of sacral region. Review of the Minimum Data Set (MDS) assessment, dated 2/11/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Additionally, he/she had a stage 3 pressure ulcer and additional non-pressure wounds requiring dressing changes. Resident #59 was followed by the Wound Physician weekly for the treatment of multiple wounds. Review of the Wound Physician's Note, dated 2/4/25, indicated but was not limited to the following: -Site 33: Non-Pressure wound of the left lateral knee: Etiology: Trauma/Injury, Wound Size: 6 x 3 x 0.1 centimeters (cm), with Moderate Serous (clear/watery) drainage; Duration: greater than 3 days. Treatment Plan recommended was Alginate Calcium (absorbs moisture/prevents infection), and Santyl (debriding agent to remove dead tissue), followed by gauze island dressing once daily. Review of the Physician's Orders indicated the treatment to the left knee was implemented on 2/6/25. Review of the nursing and physician progress notes failed to indicate the etiology of the wound and/or the associated trauma/injury. During an interview on 3/5/25 at 11:27 A.M., Consulting Staff #3 said there were no incident reports of any kind for Resident #59 for the last year. Review of the weekly skin checks and evaluations indicated but were not limited to the following: -The facility failed to complete weekly skin checks from 12/21/24 through 2/6/25. -The facility failed to complete an Admission/Readmission Evaluation in January 2025 upon return from the hospital. -2/6/25: Pressure wound on the left lateral knee. No description or measurements were documented. Review of the Wound Physician's Note, dated 2/11/25, indicated but was not limited to the following: -Site 33: Non-Pressure wound of the left lateral heel: Etiology: Trauma/Injury, Wound Size: 8 x 3 x 0.1 cm, Cluster wound: open ulceration with moderate serous drainage, Thick adherent black necrotic (dead) tissue 40%, Slough 10%, granulation (pink/red) tissue 30%, Skin intact normal color 20%; Duration: greater than 10 days. The wound was surgically debrided to remove necrotic tissue. Treatment Plan recommended was Alginate Calcium and Santyl followed by gauze island dressing once daily. -The wound to the left knee (previously documented as Site: 33) was not assessed/documented on. -Site 34: Left proximal Shin: Etiology: Infection, Wound Size 2.5 x1.1 x 0.1cm with light serous drainage. Treatment plan for Mupirocin (treats skin infectin) topical 2% followed by gauze island dressing daily. Review of the Physician's Orders indicated but were not limited to the following: -The Santyl, calcium alginate, island gauze to the left lateral knee (start 2/6/25 discontinued 2/12/25) -New order for Santyl, calcium alginate, island gauze to the left heel (start 2/13/25). -New order for Mupirocin and island dressing to left shin (start 2/13/25). Review of the Treatment Administration Record (TAR) indicated but was not limited to the following: -The treatment to the left knee was signed off as administered 2/6/25-2/12/25. -The treatment to the left heel was signed off as administered 2/13/25-2/19/25. Review of the nursing progress notes failed to indicate the discrepancy with wound location (knee vs. heel) and failed to indicate the etiology of the wound and/or the associated trauma/injury. Review of the physician progress notes indicated topical wound care as per wound team. Review of weekly skin checks failed to indicate one was completed on 2/12/25 and 2/19/25. Review of the Wound Physician's Note, dated 2/24/25, indicated but was not limited to the following -Site 33: Non-Pressure wound of the left lateral heel: Etiology: Trauma/Injury, Wound Size: 8 x 3.5 x 0.2 cm with moderate serous drainage, Thick adherent black necrotic tissue 60% and granulation tissue 40%; Wound progress: exacerbated due to infection. Treatment Plan recommended was to continue the Alginate Calcium and Santyl followed by gauze island dressing once daily and Keflex (antibiotic) 500 milligrams (mg) twice daily for 10 days. -The wound to the left knee (previously documented as Site: 33) was not assessed/documented on. -Site 34: Left proximal Shin: Etiology: Infection, Wound Size 5 x1 x 0.1cm with light serous drainage. Wound progress: exacerbated due to shear. Treatment plan for Mupirocin topical 2% followed by Xeroform (fine mesh petrolatum) gauze gauze, wrap with gauze roll daily. Review of the Physician's Orders indicated but were not limited to the following: -Keflex 500mg three times daily for 10 days. -The Mupirocin and gauze treatment to the left shin remained unchanged. The facility failed to add the Xeroform gauze. Review of the nursing progress notes failed to indicate the discrepancy with wound location (knee vs. heel), failed to indicate the recommended treatment for the shin was reviewed and declined by the physician (Xeroform), and failed to indicate the recommended Keflex was reviewed and the physician wanted to change the order from twice a day to three times a day. Review of the physician progress notes indicated topical wound care as per wound team. Review of weekly skin checks failed to indicate one was completed on 2/26/25. During an interview on 3/6/25 at 9:30 A.M., Nurse #1 said any new skin area would need an incident report/investigation, a progress note, a physician order, and to let the manager know. During an interview on 3/6/25 at 9:33 A.M., Nurse #2 said all residents should have weekly skin checks completed in the computer. Additionally, she said any new skin area would need an incident report/investigation, a progress note, a physician's order, full skin check and pain assessment, and let the manager know. During an interview on 3/6/25 at 10:31 A.M., the Director of Nurses (DON) said weekly skin checks are usually done on the shower days and documented in the electronic medical record. She said any new areas discovered would require a skin and pain assessment and an incident report. She said it is not a new process, but staff need education. She was unsure what trauma caused this injury and had no incident report for it and there was no progress note. She said the Assistant Director of Nurses (ADON) does wound rounds and she could not speak to the specifics of these wounds as she has never seen them. During an interview on 3/6/25 at 10:59 A.M., the ADON said weekly skin checks should be documented in the electronic medical record. She said any new area should have an incident report and progress note. Additionally, she said there is break in the process and she did not know why the skin checks were not done or why there was not a note and/or incident report pertaining to the trauma/injury of the knee and/or heel. Additionally, she said she should have ensured all areas had appropriate documentation and was unable to speak to the knee vs. heel as he/she has a multitude of areas on both legs or what the trauma/injury causing the wound(s) was. During an interview on 3/6/25 at 11:09 A.M., the Wound Physician said he could not access his notes to speak specifically on Resident #59's wounds, but he/she has very fragile skin. He said he recalls the heel wound because it looked like a pressure (wound). He said the day he initially saw it he had nursing management with him. He said it has deteriorated and Resident #59 is now on antibiotics for an infection. The Wound Physician said he was told by Resident #59 that he/she bumped it in the ambulance during a transfer which is why it was coded as trauma, but the facility should have documentation of that. Further review of the nursing and physician progress notes failed to indicate any reported trauma/injury and/or any investigation into the trauma/injury to the knee and/or heel and the facility failed to provide any related documentation.

Based on observations, record review, and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and to promote healing for two Residents (#2 and #59), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #2, to perform weekly skin assessments and/or monitor his/her skin until he/she developed an unstageable pressure ulcer on the left heel, and an unstageable pressure area on the left calf. The calf pressure wound required debridement and was eventually assessed as a stage 3 pressure area (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed); and 2. For Resident #59, who was identified as being at risk for skin breakdown, to obtain wound care orders on re-admission for a Stage 3 pressure area, to implement wound care orders per physician recommendations, to perform weekly skin checks, and to complete a re-admission skin assessment to ensure appropriate treatment orders were in place for the Stage 3 pressure area to promote optimal wound healing, and to develop and implement a care plan timely that identified risk factors as well as interventions designed to reduce or prevent the development of pressure related ulcers/injuries. Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated indicated but was not limited to the following: -The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. -The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, and depth, and presence of exudates (drainage) or necrotic tissue (dead tissue). b. Current treatments, including support surfaces. -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. 1. Resident #2 was admitted to the facility in April 2022 with diagnoses which included stroke with speech and language deficits, dementia, and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 11/26/24, indicated Resident #2 was at risk for pressure ulcers, and did not have one or more unhealed pressure ulcer(s) at stage 1 or higher. Review of the MDS assessment, dated 2/18/25, indicated Resident #2 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. In addition, Section GG indicates Resident #2 was dependent in rolling right and left, sit to lying and lying to sit. Resident #2 is at risk for pressure ulcers, and Resident has one stage 3. Review of Specialty Physician Wound Evaluation and Management Summary, dated 12/24/24, indicated but was not limited to the following: 1. Chief Complaint: patient has wounds on his/her left calf: left heel. -Unstageable (due to necrosis) of the left heel full thickness Etiology: pressure Duration > 4 days Wound size (Lx W x D) 4 x 3 x not measurable centimeters (cm) Depth of the wound is not measurable due to the pressure of nonviable tissue and necrosis. Surface area 12.00 cm2 Cluster wound: open ulceration area of 9.60 cm2 Thick adherent black necrotic tissue (eschar) Primary dressing: Skin prep apply once daily for 30 days Plan of care reviewed and addressed: Off-load wound; pressure off loading boots: low air loss mattress Reason for no sharp debridement: non-infected heel necrosis. 2. Unstageable (due to necrosis) of the left calf full thickness Etiology: pressure Duration > 5 days Wound size (L x W x D) 2 x 2 x 0.2 cm Depth of the wound is not measurable due to the pressure of nonviable tissue and necrosis. Surface area 4.00 cm2 Cluster wound: open ulceration area of 2.80 cm2 Exudate: Moderate serous Slough: 30% Granulation 40% Skin: intact normal color 30% Primary dressing: Alginate calcium apply once daily for 30 days Santyl apply once daily for 30 days. Gauze island with border, apply once daily for 30 days. Plan of care reviewed and addressed: Off-load wound; low air loss mattress -Surgical excisional debridement procedure: Remove necrotic tissue and establish the margins of viable tissue. Review of Resident #2's Norton Scale for Predicting Risk of Pressure Ulcer, dated 2/13/25, indicated Resident #2 scored a 7 on scale 5-20, indicating high risk for pressure development. Review of Specialty Physician Wound Evaluation and Management Summary, dated 1/6/25, indicated but was not limited to the following: -The calf pressure area was changed from an unstageable to a stage 3 pressure wound of the left calf. -Procedure today: Surgical excisional debridement was performed today on the stage 3 calf pressure. Review of specialty physician Wound Evaluation and Management Summary, dated 1/13/25, 1/20/25, and 1/27/25, indicated but was not limited to the following: -Procedure today: Surgical excisional debridement was performed today on the stage 3 calf pressure. Review of Resident #2's Physician's orders indicated but were not limited to the following: -Moisturize left heel daily, every shift. Date initiated 11/28/22. -Apply skin prep to bilateral heels daily every day and every evening shift. Date initiated 10/25/24. -Skin integrity check reminder-complete: weekly skin check evaluation every day shift every Saturday for prophylaxis. You must document skin check in the: weekly skin check evaluation. Date initiated 10/25/23. Review of the Treatment Administration Record (TAR) for December 2024 indicated but was not limited to the following: -Skin integrity check reminder- complete: Weekly Skin Check Evaluation every day shift, every Saturday for prophylaxis. You must document skin check in the Weekly Skin Check Evaluation. Date initiated 10/28/23: Weekly Skin checks were documented as being completed 12/7/24 and 12/14/24 and 12/21/24. Review of the Weekly skin check documentation indicated there was a skin check performed on 11/23/24 and not another skin check performed until 12/28/24. Review of a Daily Skilled note, completed on 12/17/24, indicated but was not limited to the following: Section D Observation and Assessment of patient condition, select all that apply. Skin integrity was not checked. No skin documentation recorded. Review of the nursing progress notes for December 2024 indicated no skin assessment or documentation until 12/24/24 at 12:58 P.M., which indicated the following: - An unstageable full thickness pressure injury of the left heel measuring 4 x3 x not measurable no drainage continues to apply skin prep daily. Unstageable full thickness pressure injury to the left calf measures 2 x 2 x 2 cm, moderate serious drainage, surgically debrided. During an interview on 3/05/25 at 4:35 P.M., the Director of Nurses (DON) said everyone has a skin check once a week and it is recorded on the skin assessment form, and she would expect the nurses to be documenting appropriately. The DON said if they find a skin issue, they fill out an incident report and an investigation is done to determine how they got the skin issue, and the appropriate treatment is put in place. The DON said the resident is then followed by risk to closely monitor the resident. The DON said she is not familiar with Resident #2's pressure areas or how he/she got them, deferring to the Assistant Director of Nurses (ADON) for specifics. During an interview with the DON present on 3/5/25 at 4:40 P.M., the ADON said it is her understanding Resident #2's left calf has a history of a left heel pressure ulcer which reoccurred, and she is unsure of how the Resident developed the left calf pressure ulcer. The surveyor and the ADON reviewed the skin documentation, dated 12/1/24 through 12/23/24, which was absent of any skin assessments or documentation. The ADON said the nurses should have been checking Resident #2's skin on a regular basis, following the physician's orders and documenting their findings in the medical record. The ADON said she was not sure why the wound doctor saw Resident #2 on 12/24/24. She said sometimes a nurse sees an area and wants the wound doctor to look at it. The ADON said that is when the two pressures areas were found, and treatment was put in place. 48084 2. Resident #59 was admitted to the facility in September 2024 with diagnoses which included Pressure Ulcer Stage 3 of sacral region. Review of the MDS assessment, dated 2/11/25, indicated Resident #59 scored 15 out of 15 on the BIMS, indicating he/she was cognitively intact. Additionally, he/she had a Stage 3 Pressure Ulcer. SEPTEMBER 2024 Review of the Nursing Admission/Readmission Evaluation, dated 9/23/24, indicated but was not limited to the following: -Section C: Skin Integrity: Coccyx (tailbone) pressure wound measuring 4 x 2 cm, Stage 3 Review of the Hospital discharge summary, dated 9/23/24, failed to indicate a pressure ulcer on the coccyx. Review of the nursing progress notes failed to indicate the pressure ulcer had been discussed with provider for a treatment plan upon admission. Review of the Physician's Orders failed to indicate a treatment had been implemented upon admission. Review of the weekly skin assessments failed to indicate one had been competed on 9/24/24. Resident #59 had been followed by the Wound Physician prior to hospitalization for wounds on the right lower extremity. Review of the Wound Physician's Note, dated 9/24/24, failed to indicate the coccyx wound had been evaluated and the wound remained without a treatment in place. OCTOBER 2024 Review of the Wound Physician's Note, dated 10/1/24, indicated a Stage 3 Pressure Wound to the coccyx measuring 2.2 x 2 x 0.4cm, with moderate serous (clear/watery) drainage and 100 % granulation tissue (red/pink tissue), duration greater than 14 days, with an objective to control odor. Dressing treatment plan indicated to apply Alginate Calcium (absorbs moisture/prevents infection), Santyl (debriding agent to remove dead tissue), followed by a gauze island dressing once daily. Review of the Physician's Orders indicated the treatment was implemented on 10/2/24. (9 days after the wound was first identified by staff). Review of the October 2024 weekly skin assessments indicated Resident #59 had a coccyx wound and was followed by the Wound Physician. Staff failed to indicate a description or measurements of the wound. Further review of the Wound Physician's Notes indicated but were not limited to the following: -10/15/24: Wound size 2.1 x 2 x 0.4 cm, moderate sero-sanguinous (clear/watery fluid and blood) drainage, 10% slough (non-viable tissue) 90% granulation tissue. Wound was surgically debrided to remove thick adherent eschar and devitalized tissue. -10/22/24: Wound size 3 x 1.8 x 0.2 cm, moderate serous drainage, 10% slough 90% granulation tissue, wound not at goal. NOVEMBER 2024 Review of the Wound Physician's Note, dated 11/5/24, indicated but was not limited to the following: -Coccyx Wound size 3 x 1.5 x 0.2 cm, heavy serous drainage, 10% slough 90% granulation tissue. Treatment plan was changed to Alginate Calcium followed by gauze island dressing once daily. Review of the Physician's Orders failed to indicate the treatment had been changed per recommendations. Review of the Primary Physician progress notes indicated wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Resident #59 was hospitalized in November 2024 unrelated to wounds. Review of the hospital discharge summary, dated 11/12/24, indicated but was not limited to the following: -Wound Care: sacrococcyx wound recommendations: Saturate gauze with Vashe (antimicrobial wound cleanser) apply directly to wound bed, soak for 5 minutes, pat dry, apply dime- thick layer of Triad (cream to maintain moist wound bed and facilitate autolytic debridement in hard to dress wounds) to wound bed, extending onto intact skin, reapply daily and as needed. Goal is to keep dime thick layer to wound bed. Review of the Physician's Orders failed to indicate the hospital discharge recommendation for treatment was implemented. The order from prior to hospitalization was continued as follows: Santyl, Alginate Calcium, followed by a gauze island dressing once daily. Review of the nursing progress notes failed to indicate the hospital recommended treatment was reviewed and declined by the physician. Review of the Wound Physician's Note, dated 11/19/24, indicated but was not limited to the following: -Coccyx: Wound size 3 x 1.2 x 0.2 cm, moderate serous drainage, 10% slough 90% granulation tissue. Treatment plan was for Alginate Calcium followed by gauze island dressing once daily. -Unstageable (pressure ulcer that cannot be staged due to depth of wound being obscured) Deep tissue Injury (DTI-usually dark purple/maroon in color and underlying tissue is difficult to assess) of the Right Buttock: Wound size 2 x 2.2 x 0.1 cm, light serous drainage, duration greater than 8 days. Treatment plan was silver sulfadiazine (topical antibiotic cream to prevent infection) daily to wound and house barrier cream to the peri wound (surrounding skin). Review of the Physician's Orders failed to indicate either treatment was implemented. Review of the Primary Physician progress notes indicated wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatments were reviewed and declined by the physician. Review of the weekly skin assessment, dated 11/21/24, indicated Resident #59 had a wound to the right buttock and was followed by the wound physician. No description or measurements were documented. The coccyx wound was omitted. Review of the Physician's Orders failed to indicate a treatment for the right buttock. Review of the Wound Physician's Note, dated 11/26/24, indicated but was not limited to the following: -Coccyx: Wound size 2 x 1 x 0.2 cm, moderate serous drainage, 10% slough 90% granulation tissue. Treatment plan was for Alginate Calcium followed by gauze island dressing once daily. -Unstageable DTI of the Right Buttock: Wound size 0.5 x 1 x 0.1 cm, light serous drainage. Treatment plan was silver sulfadiazine to the wound and house barrier cream to the peri wound. Review of the Physician's Orders failed to indicate either treatment was implemented. Review of the Primary Physician progress notes indicate wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatments were reviewed and declined by the physician. Additionally, the progress note, dated 11/26/24, indicated he/she was seen by the wound physician with no new recommendations at this time. (The recommendations on 11/26/24 were not new, they were to continue the same treatment as the week prior, and those treatments were never implemented.) Therefore, the coccyx wound continued with the wrong treatment, and the right buttock remained with no treatment in place. Review of the weekly skin assessment, dated 11/29/24, indicated he/she had a wound to the coccyx and right buttock and was followed by the wound physician. No description or measurements were documented. Review of the Physician's Orders failed to indicate a treatment for the right buttock. Review of the Primary Physician progress notes indicated wound care as per wound team. DECEMBER 2024 Review of the Wound Physician's Note, dated 12/3/24, indicated but was not limited to the following: -Coccyx: Wound size 1.8 x 1 x 0.2 cm, moderate serous drainage, 10% slough 90% granulation tissue. Treatment plan was for Alginate Calcium followed by gauze island dressing once daily. -Unstageable DTI-resolved. Review of the physician orders failed to indicate the coccyx treatment was implemented. Review of the Primary Physician progress notes indicate wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Review of the Wound Physician Notes dated 12/9/24,12/17/24, 12/24/24, and 12/31/24 continued to recommend the Treatment plan for Alginate Calcium followed by gauze island dressing once daily. Review of the Physician's Orders failed to indicate the treatment was implemented. Review of the Primary Physician progress notes indicated wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Additionally, the progress notes, dated 12/17/24, 12/24/24 and 12/31/24, indicated the treatment for the coccyx was calcium alginate followed by island gauze (per recommendation) which was not the active order in the medical record. Review of the weekly skin assessments for December 2024 indicated the following: -12/11/24 the treatment was signed off, but the assessment was not completed. -12/18/24 the treatment was signed off, but the assessment was not completed until 12/21/24 and failed to indicate a wound to the coccyx. -12/25/24 the treatment was signed off, but the assessment was not completed. JANUARY 2025 Resident #59 was hospitalized in January 2025 unrelated to wounds. Review of the medical record failed to indicate that the staff completed an Admission/Readmission Evaluation upon his/her return to the facility. Review of the Hospital Discharge Summary, dated 1/16/25, indicated but was not limited to the following: -Wound Care: Bilateral Buttocks: after skin care, apply thick layer of Coloplast Triad Hydrophilic wound paste to open wounds twice daily and as needed. Review of the Physician's Orders failed to indicate the hospital recommended treatment was implemented. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Review of the Wound Physician's Notes, dated 1/20/25 and 1/28/25, continued to recommend the Treatment plan for Alginate Calcium followed by gauze island dressing once daily. Review of the Physician's Orders failed to indicate the treatment was implemented. Review of the Primary Physician's progress notes indicated wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Additionally, the progress note dated 1/28/25 indicated that the treatment for the coccyx was calcium alginate followed by island gauze (per recommendation) which was not the active order in the medical record. Review of the weekly skin assessments for January 2025 indicated the following: -1/1/25, 1/8/25, 1/22/25, and 1/29/25 the treatment was signed off, but the assessments were not completed. FEBRUARY 2025 Review of the Wound Physician's Note, dated 2/4/25, continued to recommend the Treatment plan for Alginate Calcium followed by gauze island dressing once daily. Review of the Physician Orders failed to indicate the treatment was implemented. Review of the Primary Physician progress notes indicated wound care as per wound team. Review of the nursing progress notes failed to indicate the recommended treatment was reviewed and declined by the physician. Additionally, the progress note, dated 2/5/25, indicated the treatment for the coccyx was calcium alginate followed by island gauze (per recommendation) which was not the active order in the medical record. Review of the Wound Physician's Note, dated 2/11/25, continued to recommend the Treatment plan for Alginate Calcium followed by gauze island dressing once daily. Review of the Physician's Orders indicated the order for Alginate calcium followed by gauze island dressing once daily was implemented on 2/13/25 (100 days after it was initially recommended). Review of the weekly skin assessments for February 2025 indicated the following: -2/6/25 indicated a Stage 3 pressure wound to the coccyx. No description or measurements were documented. -2/12/25 and 2/19/25 the treatment was signed off, but the assessments were not completed. -2/26/25 the treatment was not signed off and the assessment was not completed. Review of Resident #59's comprehensive care plan indicated a care plan for the Stage 3 pressure ulcer had not been developed until 2/18/25. During an interview on 3/6/25 at 9:33 A.M., Nurse #2 said every resident should have a weekly skin check done and if a new area is noted a physician's order should be obtained for a treatment. During an interview on 3/6/25 at 10:31 A.M., the Director of Nurses (DON) said Admission/Readmission Evaluations including skin check should be done upon return and weekly skin checks should be completed usually on shower day and documented in the electronic medical record under assessments. She said if new areas are discovered, the physician should be notified for a treatment order and then put on the list for the wound doctor to see next visit. She said the Assistant Director of Nurses (ADON) does wound rounds, writes the orders and notes. The DON was unable to speak to the pressure ulcer because she said she had not seen it and did not know why the orders did not match the recommendations. She said there should have been a care plan in place for the pressure ulcer when it was discovered and was unsure why it was not implemented in September 2024. During an interview on 3/6/25 at 10:59 A.M., the ADON said she would expect any new area discovered on Admission/Readmission or during the weekly skin check to have a treatment order implemented and the wound doctor added to the profile to be seen on his next visit. The ADON said she took over wound rounds in November 2024. She was unsure why he/she did not have treatment orders in September 2024 when he/she was admitted with a pressure ulcer. She said if someone is admitted with an area and no treatment on the hospital discharge summary, the nurse should call the physician to obtain an order until he/she can be seen by the wound doctor. She said she was not sure what happened with the treatment order week after week, but the Santyl should have been removed from the order, and it was not. Additionally, she said in January 2025 there should have been an Admission/Readmission Evaluation done and it was not. She said there is a break in the process with completing the skin checks, documenting in the progress notes and ensuring orders are in place. During an interview on 3/6/25 at 11:06 A.M., the Wound Physician said the expectation is the treatment orders are written per his recommendation. He said the Santyl should have been discontinued and only the Alginate Calcium should have been continued. Additionally, he said if someone is admitted with an area without a treatment in place or obtains a new area, the nurse should call the primary physician to obtain an order until his next visit.

Based on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for 10 Residents (#65, #31, #3, #9, #26, #28, #40, #72, #17, and #21). Specifically, the facility failed: 1. For Residents #65, #31, #3, #9, #26, and #28, to initiate Transmission Based Precautions (TBP) specifically Droplet Precautions, as indicated for suspected influenza while diagnostic testing was pending; 2. For Residents #40 and #72, to ensure staff implemented appropriate use of personal protective equipment (PPE) prior to entering rooms of Residents on TBP (Droplet Precautions); 3. For Residents #17 and #21, to ensure staff implemented appropriate use of PPE for Residents positive for Influenza (FLU) on TBP (Droplet Precautions); 4. To follow infection control standards for Resident #17 while administering medications; and 5. To ensure proper cleaning of resident shared equipment during a medication pass. Findings include: Review of the facility's policy titled Clinical Services Subject: Precautions to Prevent Infection, dated as revised 12/2023, indicated, but was not limited to the following: -Transmission-Based Precautions (TBP) are for patients who are known or suspected to be infected with infectious agents, which require additional control measures to effectively prevent transmission. -Transmission-Based Precautions determines the type of PPE to be used. -Communication (written, verbal reports, signage) regarding the particular type of precaution to be utilized. -Droplet Precautions are intended to prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. -Infectious agents for which Droplet Precautions are indicated include influenza virus. Implementation of Precautions -TBP must be implemented while tests are pending based on the clinical presentation and likely pathogens. -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE. -Make PPE available immediately outside of the resident room. -Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 1A. Resident #65 was admitted to the facility in November 2021. Review of the nursing progress notes indicated but were not limited to the following: -2/24/25 he/she presented with cold symptoms and COVID test was negative. -2/28/25 he/she had cold symptoms, testing for influenza A/B and RSV was ordered, and he/she was started on Tamiflu (medication to treat and prevent influenza). Review of the physician's orders and care plan failed to indicate Droplet Precautions were implemented for suspected influenza pending the results of the diagnostic testing. Surveyor Observations throughout the day on 2/28/25, 3/3/25, and the morning of 3/4/25 failed to indicate Droplet Precautions were implemented. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. Review of the initial lab report provided indicated the results were still pending on 3/4/25. B. Resident #31 was admitted to the facility in November 2017. Review of the nursing progress notes indicated but were not limited to the following: -2/24/25 he/she presented with cold symptoms and COVID test was negative. -3/2/25 he/she had a productive cough, and he/she was started on Tamiflu. The facility failed to provide test results/report stating it was still pending. Review of the physician's orders and care plan failed to indicate Droplet Precautions were implemented for suspected influenza. Surveyor Observation throughout the day on 2/28/25, 3/3/25, and the morning of 3/4/25 failed to indicate Droplet Precautions were implemented. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. C. Resident #3 was admitted to the facility in December 2024. Review of the nursing progress notes indicated but were not limited to the following: -2/26/25 he/she was swabbed to rule out influenza and RSV. -2/28/25 he/she was lethargic with a cough. -2/28/25 he/she tested positive for influenza A Review of the lab result indicated the results were reported on 2/28/25 at 4:21 P.M. Surveyor Observation throughout the day on 2/28/25 failed to indicate Droplet Precautions were implemented for suspected influenza. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. Review of the physician's orders failed to indicate Droplet Precautions were implemented for suspected influenza. Review of the care plan indicated Droplet Precautions were implemented on 3/1/25 for Influenza A. D. Resident #9 was admitted to the facility in December 2024. Review of the nursing progress notes indicated but were not limited to the following: -2/26/25 he/she was swabbed to rule out influenza and RSV. -2/28/25 he/she tested positive for influenza A and was started on Tamiflu Review of the lab result indicated the results were reported on 2/28/25 at 4:22 P.M. Surveyor Observation throughout the day on 2/28/25 failed to indicate Droplet Precautions were implemented for suspected influenza. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. Review of the physician's orders failed to indicate Droplet Precautions were implemented for suspected influenza. Review of the care plan indicated Droplet Precautions were implemented on 3/1/25 for Influenza A. E. Resident #26 was admitted to the facility in February 2025. Review of the nursing progress notes indicated but were not limited to the following: -2/26/25 he/she was swabbed to rule out influenza and RSV. -2/28/25 he/she tested positive for influenza A Review of the lab result indicated the results were reported on 2/28/25 at 4:22 P.M. Surveyor Observation throughout the day on 2/28/25 failed to indicate Droplet Precautions were implemented. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. Review of the physician's orders failed to indicate Droplet Precautions were implemented for suspected influenza. Isolation Precautions were implemented on 2/28/25, after the positive result came back. Review of the care plan indicated Droplet Precautions were implemented on 3/1/25 for Influenza A. F. Resident #28 was admitted to the facility in October 2017. Review of the nursing progress notes indicated but were not limited to the following: -2/28/25 he/she had a productive cough and shortness of breath and labs were pending Review of the lab result indicated the sample was collected on 2/28/25 and results were reported negative on 3/4/25 at 1:18 P.M. Review of the physician's orders and care plan failed to indicate Droplet Precautions were implemented for suspected influenza while the test was pending. Surveyor Observation throughout the day on 2/28/25, 3/3/25, and the morning of 3/4/25 failed to indicate Droplet Precautions were implemented. There was no Droplet Precaution signage on/outside the door to his/her room. The facility failed to alert Staff, Visitors, and Surveyors of the suspected illness and need for additional precautions. Staff were observed in the room with the Resident without proper PPE on. During an interview on 3/4/25 at 10:41 A.M., the Director of Nurses (DON) provided the surveyor with an updated list of residents positive for influenza and stated there were still two more swabs pending since 2/28/25. She said she called the lab to inquire on them because they were taking a long time. The surveyor reviewed the list of positive cases and pending swabs with the DON. The DON said she did not know why precautions were not implemented when the residents became symptomatic, and the flu swab was obtained. During an interview on 3/4/25 at 11:28 A.M., the Assistant Director of Nurses (ADON) said if a resident had a flu swab pending, they would go on droplet precautions until the test resulted. During an interview on 3/4/25 at 11:32 A.M., Nurse #2 said she was not aware of any pending flu swabs, but if someone was symptomatic and had a test pending, they should go on droplet precautions until the test resulted. During an interview on 3/4/25 at 11:32 A.M., the ADON said there were three residents with swabs pending, and they should all be on precautions and were not. She was unsure why the precautions were not implemented as they should have been. During an interview on 3/4/25 at 11:58 A.M., Consulting Staff #3 said anyone with a swab pending should have Droplet Precautions in place until the test results are reported. During an interview on 3/4/25 at 12:05 P.M, the DON said any resident with a swab pending should have Droplet Precautions implemented immediately, and they should remain in place until the test results. Additionally, she said the Droplet Precautions should have been in place when the swabs were obtained, and they were not put in place until the result came back positive. 28450 2. On 2/28/25 at 10:18 A.M., the surveyor observed signage at the entrance to the rooms of Resident #40 and Resident #72 which indicated DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before exiting the room. The PPE cart was outside of each of the rooms' entrance. The surveyor observed a staff member, wearing only a mask, enter the rooms of the two residents that were on droplets precautions. The staff member left both rooms and did not change her mask. On 2/28/25 at 10:32 A.M., the surveyor observed three CNAs walk in Resident #40 and #72's rooms to assist with care and were not wearing masks and eye protection. The signs at the door indicated (Make sure their eyes, nose and mouth are fully covered before room entry). On 2/28/25 at 10:35 A.M., the surveyor observed the regional nurse walk in and out of Resident #40 and Resident #72's rooms without applying a clean mask prior to entering and leaving. The droplets precautions sign was posted. During an interview on 3/5/25 at 2:32 P.M., Certified Nursing Assistant (CNA) #10 said before entering a room on transmission base precautions you must sanitize your hands apply gown, goggles, and an N-95 is used for droplets. She said most importantly prior to entering the room a resident on isolation precautions you must stop to review the sign at the door post for instructions. She added prior to leaving the room you must remove the PPE by the door dispose of them in the covered can, sanitize your hands, and apply a new mask. During an interview on 3/4/25 at 4:29 P.M., Nurse #5 said when entering the room of a resident on transmission base precautions, you must apply a fresh mask, to go in and out, before coming out you must dispose of the mask in the room, sanitize your hands, and apply a fresh mask. During an interview on 3/4/25 at 4:36 P.M., Nurse #8 said when entering the room of a resident on transmission base precautions, you must apply a fresh mask, to go in and out, before coming out you must dispose of the dirty mask in the room, sanitize your hands, and apply a new mask. During an interview on 3/7/25 at 1:40 P.M., the DON said staff are not to enter rooms on TBP (Droplet Precautions), without wearing proper PPE. 49425 3. During entrance conference on 2/28/25 at 9:54 A.M., the Administrator said the facility currently had four residents positive for flu on the west wing and two residents positive for the flu that were currently at the hospital. a. During an observation with an interview on 3/3/25 at 12:02 P.M., the surveyor observed a Droplet Precaution sign posted outside the door to Resident #21's room indicating staff were required to clean hands when entering and exiting, make sure eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. The surveyor observed CNA #4 enter Resident #21's room, wearing only a surgical face mask, no goggles or face shield was worn. Prior to exiting the room, CNA #4 did not remove his surgical mask. A PPE bin was located in front of the room stocked with surgical masks. There were no face shields or goggles in the PPE bin for use. CNA #4 said Resident #21 is on precautions for the flu. CNA #4 reviewed the Droplet Precautions sign and said he should have worn eye protection, and changed his mask when he exited the room. He said there were no goggles or face shields to use in the PPE bin. CNA #4 said this is his first day here, and is not sure where to get more PPE from. On 3/3/25 at 3:47 P.M., the surveyor observed Rehabilitation Staff #2 in Resident #21's room, wearing only a surgical face mask. No goggles or face shield was worn. The room had a Droplet Precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, make sure eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. A PPE bin was located next to the door stocked with surgical masks. There were no face shields or goggles in the PPE bin for use. The surveyor observed Rehabilitation Staff #2 exit the room, perform hand hygiene and begin walking down the hallway. During an interview on 3/3/25 at 3:58 P.M., Rehabilitation Staff #2 said she was speaking to Resident #21's roommate, who is not on precautions, that is why she was not wearing any eye protection. Rehabilitation Staff #2 reviewed the Droplet precaution sign and said she should have worn eye protection to enter the room and changed her mask upon exiting. On 3/4/25 at 8:42 A.M., the surveyor observed a PPE bin located outside of Resident #21's room. The PPE bin did not have any face shields or goggles available for use. b. On 3/3/35 at 11:59 A.M., the surveyor observed a Droplet Precaution sign posted outside the door to Resident #17's room indicating staff were required to clean hands when entering and exiting, make sure eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. The surveyor observed CNA #5 enter Resident #17's room, carrying a lunch tray. CNA #5 was wearing only a surgical face mask, no goggles or face shield was worn. CNA #5 exited the room, completed hand hygiene, and approached the food truck that was placed in the hallway. CNA #5 did not remove her surgical mask prior to exiting the room. A PPE bin was located next to the door of the room stocked with surgical masks and face shields. During an interview on 3/3/25 at 12:06 P.M., CNA #5 said Resident #17 is positive for the flu, and is on Droplet Precautions. She said she is only required to wear eye protection if she is providing direct care. CNA #5 reviewed the Droplet Precaution sign and said she is supposed to wear a face shield when entering the room and remove it when exiting. She said she made a mistake, and thought it was just for direct care. During an observation with an interview on 3/4/25 at 8:50 A.M., the surveyor observed Activity Assistant #1 enter Resident #17's room wearing only a surgical face mask, no goggles or face shield was worn. The room had a Droplet Precaution sign posted outside the door indicating staff were required to clean hands when entering and exiting, make sure eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Activity Assistant #1 then exited the room and walked down the hall. Activity Assistant #1 did not perform hand hygiene or change her face mask upon exiting the room. She said she should have cleaned her hands and changed her mask when she left the room. She said she should have been wearing a face shield to help stop the spread of germs but forgot to put one on. A PPE bin was located outside of the Resident's room stocked with surgical face masks and face shields and an alcohol-based hand sanitizer pump (ABHS) was located on the wall outside of the room to complete hand hygiene. During an interview on 3/4/25 at 8:55 A.M., the Director of Housekeeping (DOH) said housekeeping staff is responsible for stocking the PPE bins in the facility twice a day, once in the morning and once in the afternoon. He said all bins are stocked with gloves, gowns, N95 (respirator) masks, surgical face masks, and face shields, regardless of what precaution sign is used. The DOH said the nursing staff has access to the PPE stock and can get more supplies at any time if needed. The surveyor and DOH observed the PPE stockroom and noted multiple boxes of face shields in stock for use. During an interview on 3/4/25 at 10:52 A.M., the Director of Nursing (DON) said all staff is supposed to adhere to the precaution signs posted outside of the resident rooms, and wear the proper PPE required. She said housekeeping stocks the PPE bins daily and the nursing staff also has the capability to get more supplies; no one should be entering a Droplet Precaution room without eye protection. She said the bins should have had face shields for the staff to utilize. The DON said the facility does not have anyone supervising proper PPE use on the units. 4. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: -The Director of Nursing services supervises and directs all personnel who administer medications -Medications are administered in a safe manner -Staff follow established facility infection control procedures for the administration of medications. Resident #17 was admitted to the facility in December 2023 with a diagnosis of conversion disorder with seizures. On 3/3/25 at 8:45 A.M., the surveyor observed Nurse #6 prepare and administer medication to Resident #17 as follows: -Phenobarbital 32.4 milligrams (mg) (treats seizures) three tablets by mouth (PO) two times a day -Tamiflu 75 mg (treats flu) one tablet PO two times a day for five days -Protonix 40 mg (treats gastric reflux) one tablet PO BID -Aspirin 81 mg (supplement) one tablet PO daily -Keppra 500 mg (treats seizures) one tablet PO two times daily -Olmesartan 40 mg (treats high blood pressure) PO daily -Vitamin D3 400 units (U) (supplement) PO daily The surveyor observed Nurse #6 remove three Phenobarbital 32.4 mg tablets from a blister pack and place them into a medication cup. One of the Phenobarbital 32.4 mg tablets missed the cup and landed on top of the narcotic book on the medication cart. Nurse #6 picked up the Phenobarbital 32.4 mg tablet with her bare hands and placed it into the medication cup with the other medications. She then administered all the medications to Resident #17. During an interview on 3/3/25 at 9:42 A.M., Nurse #6 said when a medication falls onto the medication cart, it is considered dirty and should be destroyed. She said the pill that fell was a narcotic and that is why she administered it to the Resident. She said she should have taken the time to have it destroyed with another nurse and given the Resident a new pill. During an interview on 3/3/25 at 10:56 A.M., the DON said medications that fall onto any surface are considered contaminated and should not be administered to the Resident. The DON said her expectation is for the nurse to destroy the medication, with another nurse, and administer a new pill. 5. Review of the facility's policy titled Cleaning Reusable Equipment, undated, indicated but was not limited to the following: -Reusable Equipment is to be cleaned between resident use and reprocessed appropriately. -The facility must protect indirect transmission through decontamination (cleaning, sanitizing, or disinfecting) of an object to render it safe for handling. -The employee will disinfect reusable equipment between resident uses or before transport using a designated house disinfectant. -Equipment: Blood Pressure Cuffs (BP) Frequency: between residents Accountability: individual performing task On 3/3/25 at 9:29 A.M., the surveyor observed Nurse #6 enter a resident's room with an automatic blood pressure machine on wheels. Nurse #6 applied the blood pressure cuff to the resident's arm and took the blood pressure. She then removed the machine and placed it in the hallway and returned to her medication cart. Nurse #6 did not disinfect or clean the blood pressure cuff before or after use. Stored in a basket attached to the blood pressure machine was a container of germicidal disposable wipes, used for disinfecting equipment. During an interview on 3/3/25 at 9:42 A.M., Nurse #6 said she is supposed to clean reusable equipment after use and just forgot. During an interview on 3/3/25 at 10:56 A.M., the DON said any shared resident equipment must be cleaned after use, because it has a high risk of spreading bacteria to another resident. She said it is best practice to clean all shared equipment before and after use, to reduce the risk of spreading germs.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, and on 6/23/24 during the overnight shift had been heard calling out for help and was found on the floor by two Certified Nurse Aides (CNAs) after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of practice, when although Nurse #1 went to Resident #1's room with the two CNA's to check him/her, after a brief assessment Nurse #1 assisted the CNA's with lifting him/her off the floor and putting him/her back in to bed. However, Nurse #1 did not document the incident, did not complete an incident report, did not report the incident to the oncoming nurse during shift change report and there was no documentation in Resident #1's medical record to support she had adequately assessed him/her after the fall. Resident #1 verbalized complaints of pain in his/her left upper leg/thigh area for the next two shifts after the incident, and approximately 24 hours after the incident, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she was diagnosed with acute fractures of the pelvis. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility Policy titled, Falls - Clinical Protocol, undated, indicated the following: -the staff will evaluate, and document falls both witnessed and unwitnessed that occur while the resident is in the facility, when and where they happen and any observations of the events; -the staff will follow up on any fall with associated injury until the resident is stable. Review of the Facility Policy, titled, Accidents and Incidents - Investigating and Reporting, undated, indicated the following: -all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator; -the charge nurse shall promptly initiate and document investigation of the accident or incident; -the following date shall be included on the Report of Incident/Accident: date and time of accident or incident took place; nature of the injury, circumstances surrounding the accident or incident; where the accident or incident took place; name of witnesses and their accounts of the accident or incident; the time the physician was notified and his/her instructions; the condition of the resident, including vital signs, the signature and title of the person completing the report; -charge nurse shall complete a Report of Incident/Accident form and submit the original to the Director of Nurses (DON) within 24 hours of the incident or accident; -the DON shall ensure that the administrator receives a copy of the Report of Incident/Accident form for each occurrence. Resident #1 was admitted to the Facility in May 2024, diagnoses included osteoarthritis of the knee, chronic kidney disease, repeated falls, hypertension, depression, disorientation and atherosclerotic heart disease Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 07/01/24, indicated that on 06/23/24 at approximately 3:00 A.M., Resident #1 was found by Certified Nurse Aide (CNA) #1 and CNA #2 lying flat on his/her back on the floor with his/her feet towards the side of the bed and his/her head towards the door of his/her room. The Report indicated Nurse #1 assessed Resident #1 and he/she complained of back pain. The Report indicated that CNA #1, CNA #2 and Nurse #1 assisted Resident #1 back into bed and Resident #1 began complaining of leg pain. The Report indicated Nurse #1 administered pain medication with moderate effect. The Report indicated that Nurse #2 assumed care of Resident #1 from 7:00 A.M. through 11:00 P.M. on 6/23/24. The Report indicated throughout the day, Resident #1 complained several times of 10/10 pain in his/her groin and leg and pain worsened with movement. The Report indicated Nurse #2 notified the physician and orders were obtained for pain management. The Report indicated that at the end of Nurse #2's shift, Resident #1 as observed lying in bed and had no complaints of pain. The Report further indicated that Nurse #3 assumed care of Resident #1 at 11:00 P.M. and assessed Resident #1 shortly after the start of the shift. The Report indicated that Nurse #3 assessed Resident #1 hips by applying light pressure, he/she screamed out in pain, and stated his/her pain was 10/10 when his/her left lower extremity was moved, and he/she could not move his/her left lower extremity. The Report indicated that Nurse #3 notified the physician and Resident #1 was transferred to the Hospital ED at 2:30 A.M. on 6/24/24. The Report indicated Resident #1 was diagnosed with acute fractures of the left anterior acetabulum and left inferior pubic ramus (pelvic fractures). During a telephone interview on 07/16/24 at 08:00 A.M., (which included a review of her Written Witness Statement, dated 06/24/24), CNA #1 said on 06/23/24, somewhere around 2:30 A.M.- 3:00 A.M. (exact time unknown) she heard someone calling out help, she walked down the hall, went into Resident #1's room and found him/her lying on his/her back on the floor in his/her room. CNA #1 said she went to get help and CNA #2 and then Nurse #1 came into Resident #1's room. CNA #1 said that Resident #1 was complaining that his/her back hurt, that Nurse #1 checked his/her back and all three of them transferred Resident #1 into bed by lifting his/her body and putting him/her back into bed. During an interview on 07/15/24 at 03:20 P.M., (which included a review of her Written Witness Statement, dated 06/24/24), CNA #2 said on 06/23/24, sometime around 2:30 A.M. (exact time unknown) she was in the dining room when CNA #1 entered and informed her that a resident was on the floor. CNA #2 said that she and CNA #1 went into Resident #1's room and found him/her lying on his/her back on the floor in front of the bathroom door of his/her room. CNA #2 said that they called out for the Nurse (later identified as Nurse #1), Nurse #1 entered the room with a blood pressure cuff, obtained Resident #1's blood pressure and then all three of them transferred Resident #1 back into bed by lifting his/her body and putting him/her into bed. CNA #2 said that Resident #1 kept yelling out my head, my leg, hurts during the transfer and after he/she was lying in bed. CNA #2 said that Nurse #1 gave Resident #1 pain medication and told her (CNA #2) that Resident #1 was okay. CNA #2 said that Nurse #1 did not ask her for a statement about the incident. CNA #2 said later that same day (6/23/24) she returned to work on the same unit for the 3:00 P.M. to 11:00 P.M. shift. CNA #2 said that Resident #1 was yelling out in pain during the shift. CNA #2 said that she believed that the nurses on that shift were aware that Resident #1 had fallen during the overnight shift because the nurses give each other report, so she assumed that the nurses were aware. During an interview on 7/15/24 at 04:15 P.M., (which included a review of her Written Witness Statement, dated 06/23/24), Nurse #2 said that during change of shift report on 6/23/24, from the 11:00 P.M. to 07:00 A.M. nurse (later identified as Nurse #1), Nurse #1 shared that Resident #1 had almost fallen, but had not and that he/she was fine. Nurse #2 said that after report, she went in to assess Resident #1, said Resident #1 was in bed and when asked if he/she had pain, he/she pointed to his/her left upper leg/thigh area and began to yell out in pain. Nurse #2 said she administered Tylenol to Resident #1, checked on him/her later and Resident #1 said he/she did not have any effect from the Tylenol. Nurse #2 said she administered Tramadol (pain reliever for moderate to severe pain) and Resident #1 did not have any effect from the Tramadol. Nurse #2 said that when she moved Resident #1's left leg, he/she cried out in pain. Nurse #2 said she notified the physician of Resident #1's pain, of her interventions and said the physician ordered Ibuprofen 800 milligrams (mg) one time dose and to not move Resident #1's left leg, that the MD said he believed he/she had a stiff leg which would self-resolve. Nurse #2 said that she followed the physician's orders and later on the 03:00 P.M. to 11:00 P.M. shift, Resident #1 continued to complain of pain, that she notified the physician several times on 06/23/24 of Resident #1's unresolved pain and he ordered another dose of Tramadol and scheduled his/her Tylenol to three times a day. Nurse #2 said that Resident #1's pain medication was effective if she did not move his/her left lower extremity. Nurse #2 said she was not aware that Resident #1 had fallen on 6/23/24, during the overnight shift. CNA #1 said that she worked the 11:00 P.M. to 07:00 A.M. shift (from 6/23/24 into 6/24/24) and when she came on duty, she told the Nurse (later identified as Nurse #3) that she did not write a statement about Resident #1's fall last night. CNA #1 said that Nurse #3 said he was unaware of Resident #1's fall, said Nurse #3 then called the Director of Nurses (DON) and Resident #1 was transferred to the hospital. During an interview on 7/15/24 at 04:45 P.M., (which included a review of his Written Witness Statement, undated,) Nurse #3 said that during change of shift report from the 3:00 P.M. to 11:00 P.M. nurse (later identified as Nurse #2) that Nurse #2 had said that Resident #1 was in excruciating pain the whole day. Nurse #3 said that Nurse #2 said that she notified the physician and received multiple orders for pain management. Nurse #3 said that he asked Nurse #2 if Resident #1 had fallen and said Nurse #2 said she had not received any reports that Resident #1 had sustained a fall. Nurse #3 said that the CNA (later identified as CNA #1) who had worked that overnight shift (06/24/24) was the one that told him that Resident #1 had fallen the previous night. Nurse #3 said he then completed a head-to-toe assessment on Resident #1 who stated he/she was experiencing a 10/10 pain in his/her left lower extremity and screamed out in pain when he lightly pressed on Resident #1's left hip area and said Resident #1 was unable to move his/her left lower extremity. Nurse #3 said he notified the DON, notified the physician and Resident #1 was transferred to the Hospital ED for evaluation. During a telephone interview on 7/16/24 at 1:33 P.M., (which included a review of her Written Witness Statement, dated 6/25/24), Nurse #1 said that on 6/23/24, sometime around 03:30 A.M. (exact time unknown), one of the CNA's notified her and the other CNA that she heard help help and thought that a resident had fallen. Nurse #1 said that the two CNA's (later identified as CNA #1 and CNA #2) went into Resident #1's room and she followed them. Nurse #1 said that when she entered Resident #1's room, he/she was in a near falling position, with his/her legs and feet dangling on the floor sliding off the bed and his/her upper body was sliding off the bed, and it looked like he/she was trying to reach the bedside commode. Nurse #1 said that she asked Resident #1 if he/she was okay and said that Resident #1 said he/she was okay and just needed to go to the bathroom. Nurse #1 said that the CNA's transferred Resident #1 onto the commode and then transferred him/her back into bed. Nurse #1 said that she obtained Resident #1's vital signs and assessed him/her for injury and that no injuries were noted. Nurse #1 said that a few minutes later, Resident #1 complained of back pain and she administered Tylenol to him/her. Nurse #1 said that for the remainder of the shift, Resident #1 did not complain to her of any pain. Nurse #1 said that she reported to the next shift nurse that Resident #1 almost fell and that she gave him/her Tylenol for back pain. Nurse #1 said that she thought she wrote a nurse progress note about the incident and said she thought she documented that she administered Tylenol to Resident #1 for back pain. Nurse #1 said she should have written a nurse progress note about the incident and should have documented that she administered Tylenol to Resident #1. Nurse #1 said that she did not complete an incident report, did not notify the DON, and did not notify the physician because Resident #1 did not fall. Although Nurse #1's Written Witness Statement and Telephone Interview indicated she found Resident #1 in a near falling position on 06/23/24 at approximately 3:30 A.M., review of Resident #1's Medical Record indicated there was no documentation to support this, and no documentation to support that Nurse #1 had assessed Resident #1 after the incident, documented the incident in a nurses note, completed an Incident Report, notified the Director of Nurses or notified Resident #1's physician, per Facility Policy. The Facility was unable to provide any documentation related to Resident #1's incident on 06/23/24. The was no documentation to support Nurse #1 had assessed Resident #1 for potential injury or pain as a result of the fall. Review of a Hospital Discharge Summary Report, dated 06/24/24, indicated that Resident #1 presented after a fall with left knee, hip, groin and leg pain. The Report indicated that a Pelvic CT scan revealed acute fractures of left anterior acetabulum and left inferior pubic ramus (fractured pelvis). During an interview on 07/15/24 at 3:41 P.M., the Director of Nurses (DON) said that Resident #1 was at high risk for falls and had a history of multiple falls at home. The DON said that Resident #1's injuries were consistent with injuries sustained after a fall and said that near fall incidents are still considered a fall. The DON said she could not find any documentation in Resident #1's Medical Record regarding his/her fall on 06/23/24. The DON said it was her expectation that Nurse #1 should have assessed Resident #1 for injury, documented it in a Nurse's Note, completed an Incident Report, notified the physician and notified her (DON), but she had not.

Based on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#53), out of a total sample of 20 residents, when the facility was unable to reach the Resident's primary care physician for new pain management orders based on Hospice recommendations, resulting in the Resident suffering very severe pain of 7/8 on a scale of 1-10 with 10 being the worst pain for more than 24 hours after the Hospice recommendation was made. Findings include: Review of the facility's policy titled Pain Assessment and Management, last revised 7/2023, included but was not limited to: -The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and address the underlying causes of pain. Guidelines: -The pain management program is based on a facility-wide commitment to resident comfort. -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. -Pain management is a multidisciplinary care process that includes the following: -effectively recognizing the presence of pain -identifying the characteristics of pain -monitoring for the effectiveness of interventions; and -modifying approaches as necessary. -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Recognizing Pain: -Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. -Possible behavioral signs of pain: Verbal expressions such as groaning, crying, screaming; Facial expressions such as grimacing, frowning, clenching of the jaw, etc. -Review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medications relieve the resident's pain. Assessing Pain: -Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. -Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain. Identifying the Causes of Pain: -Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: Skin/Wound Conditions: Pressure, venous or arterial ulcers; End of life/Hospice Care -Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: -Bathing, dressing, or other activities of daily living (ADLs) -Treatments such as wound care or dressing changes -Turning or repositioning. Defining Goals and Appropriate Interventions: -The pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. Implementing Pain Management Strategies: -The physician and staff will establish a treatment regimen based on consideration of the following: The resident's medical condition; Current medication regimen; Nature, severity and cause of the pain; Course of the illness; Treatment goals Monitoring and Modifying Approaches: -Re-assess the resident's pain and consequences of pain at least every shift for acute pain or significant changes in levels of chronic pain -Monitor the following factors to determine if the resident's pain is being adequately controlled: -The resident's response to interventions and level of comfort over time -Monitor the resident by performing basic assessment with enough detail and, as needed, with standardized assessment tools and relevant criteria for measuring pain management -If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Reporting: Report the following information to the physician or practitioner: -Significant changes to the level of the resident's pain. -Prolonged, unrelieved pain despite care plan interventions. Resident #53 was admitted to the facility in July 2022 and had diagnoses including heart failure, dementia, venous insufficiency, and bilateral stage 4 pressure ulcers (a full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the heel. Review of the Hospital Discharge Summary, dated 1/8/24, indicated Resident #53 was admitted to the hospital on 12/31/23 and treated for a urinary tract infection and sepsis (infection of the blood stream). The discharge summary indicated the Resident had no clinical improvement, showed signs of progressive clinical and mental deconditioning. The discharge summary indicated the Resident was receiving the following medication for pain management: -Morphine 0.125 ml (milliliters)/2.5 mg (milligrams) - 0.25 ml/5 mg by mouth every four hours as needed; give 0.125 ml for mild to moderate pain and 0.25 ml for severe pain. Review of the Physician's Orders for pain management, dated 1/8/24, indicated: -Morphine Sulfate Oral Solution 20 mg/5 ml, give 0.125 ml (2.5 mg) every 4 hours as needed for mild to moderate pain or dyspnea (shortness of breath) -Morphine Sulfate (Concentrate) Solution 20 mg/ml, give 0.25 ml (5 mg) every 4 hours as needed (prn) for severe pain -Pain Evaluation every shift: 0=none 1-2=mild 3-4=moderate 5-6=severe 7-8= very severe 9-10=worst possible If pain value greater than 0, please refer to prn medications for actions Medical record review failed to indicate that a comprehensive pain assessment was conducted upon re-admission to the facility, per facility policy. Review of Resident #53's Pain Care Plan, initiated 7/5/22 (never updated), included: -Focus: The resident has pain relating to weakness -Interventions Administer medications per orders; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate effectiveness of pain interventions routinely; Monitor/report to nurse resident complaints of pain or requests for pain treatment; Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experiences of pain. -Goal: The resident will not have an interruption in normal activities due to pain through the review date (target date 4/10/24) Review of the medical record indicated that on 1/9/24, a physician's order was obtained and the family was in agreement for a referral to the Hospice provider to screen and admit the Resident to services if appropriate. Review of the January 2024 Medication Administration Record (MAR) and the corresponding narcotic book (written ledger to maintain accurate records of all controlled drugs administered by the facility), indicated the Resident received the following doses of Morphine: -1/9/24 at 5:22 A.M., 0.125 ml/2.5 mg was administered for a pain level of 7 (according to the facility pain scale, should have administered 5 mg), dose administered was documented as effective -1/9/24 at 9:41 A.M., 0.25 ml/5 mg was administered for a pain level of 7, dose administered was documented as effective -1/9/24 at 2:30 P.M., 0.25 ml/5 mg was administered for a pain level of 5, dose administered was documented as effective -1/9/24 at 6:30 P.M., 0.25 ml/5 mg was administered for a pain level of 7, no effectiveness of dose noted -1/9/24 at 10:30 P.M., 0.25 ml/5 mg was administered for a pain level of 7, no effectiveness of dose noted -1/10/24 at 2:30 A.M., 0.25 ml/5 mg was administered for a pain level of 7, effectiveness documented as unknown -1/10/24 at 6:30 A.M., 0.25 ml/5 mg administered for a pain level of 6, dose administered was documented as effective -1/10/24 at 11:13 A.M., 0.25 ml/5 mg administered for a pain level of 8, dose administered was documented as effective -1/10/24 at 3:30 P.M., 0.25 ml/5 mg was administered for a pain level of 7, no effectiveness of dose noted Review of the Hospice Nurse's Narrative Note/Recommendations, signed and dated 1/10/24, indicated the following: -Hospice Nurse #1 collaborated with Nurse #1 and assessed Resident #53. -The Resident was admitted to Hospice services. -Recommendations included, but were not limited to: -Discontinue Morphine Sulfate 20 mg/ml: 0.125 ml every 4 hours as needed; Morphine Sulfate 20 mg/ml 0.25 ml every 4 hours as needed. -Please change Morphine Sulfate 20 mg/ml to 0.5 ml every 4 hours as needed for pain. Review of a Nurse's note, dated 1/10/24, indicated Resident #53 was in pain and moaning with care. Three attempts were made to contact the attending physician with Hospice recommendations with no return call (note written at 10:43 P.M.). During an interview on 1/16/24 at 11:10 A.M., Nurse #1 said she has cared for Resident #53 since she started at the facility and he/she was on her regular assignment. She said the Resident was in a lot of pain after being readmitted from the hospital. She said the medications that were being administered for pain were not managing it and he/she would scream out any time ADL care was provided. She said on 1/10/24, Hospice came in to admit the Resident to services and made a recommendation to increase the dose of Morphine to alleviate the pain. Nurse #1 said the Hospice nurse tried calling the physician, but there was no answer and could not leave a message because the voice mailbox was full. She said she tried calling the physician before the Hospice nurse left, and there was no answer and the voice mailbox was full. Nurse #1 said that she has not spoken to or seen Physician #1 since he/she returned from the hospital. During an interview on 1/16/24 at 12:58 P.M., Hospice Nurse #1 said she came to the facility on [DATE] at 2:30 P.M., screened and admitted Resident #53 to Hospice services. She said the Resident was in a lot of pain and exhibited facial grimacing, groaning, and moaning during her assessment and said his/her pain was not being managed. Hospice Nurse #1 said Nurse #1 told her they were giving the Resident Morphine according to physician's orders, but it wasn't enough to manage the pain. The Hospice nurse said she documented her recommendation to increase the Morphine dose to Morphine 20 mg/ml 0.5 ml every 4 hours as needed for pain and tried to call Physician #1 herself at 2:30 P.M. on the facility's phone to obtain approval for the recommendation, but the call went to voicemail. She said there was no way to leave a message because the voice mailbox was full. Hospice Nurse #1 said she observed Nurse #1 attempt to call the physician from the facility phone as well, and there was no answer and the voice mailbox was full. Hospice Nurse #1 said the oncoming nurse, Nurse #12, said she would attempt to call and text the physician as well. Further review of the January 2024 MAR indicated Morphine was administered as follows: -1/10/24 at 9:30 P.M., 0.25 ml/5 mg, no pain level or effectiveness of dose documented. -1/11/24 at 1:30 A.M., 0.25 ml/5 mg, for a pain level of 7, unknown effectiveness -1/11/24 at 5:30 A.M., 0.25 ml/5 mg for a pain level of 7, effective Review of a Nurse's Note, dated 1/11/24 at 8:03 A.M., indicated the Resident was alert and moaning with care. Nursing staff were waiting for the physician to approve the Hospice recommendations to increase the Morphine dose. On 1/11/24 at 8:38 A.M., the surveyor observed Resident #53 lying supine in bed. The Resident was unable to verbally respond to the surveyor's questions about his/her pain. The Resident attempted to shift his/her weight and grimaced on two occasions. Further review of the January 2024 MAR indicated: -1/11/24 at 9:54 A.M., 0.25 ml/5 mg for a pain level of 8, ineffective -1/11/24 at 2:14 P.M., 0.25 ml/5 mg for a pain level of 8, ineffective Review of Hospice Narrative Note/Recommendations, signed and dated by Hospice Nurse #2 on 1/11/24, included but was not limited to: Resident appears to be actively dying at this time. Minimally responsive and lethargic. Patient showing signs and symptoms of severe pain with any attempt to move extremities or reposition. Facility nurses have been consistently medicating patient with 5 mg Morphine every 4 hours prn with little effect. Hospice recommendations: -Schedule Morphine (20 mg/ml) 10 mg (0.5 ml) every 4 hours. -Change prn Morphine to 5 mg (0.25 ml) every 2 hours prn for pain or shortness of breath. During an interview on 1/16/24 at 1:15 P.M., Hospice Nurse #2 said she came to the facility on [DATE] at 3:15 P.M. for a 24-hour follow-up visit and learned the Resident's Physician had not responded to facility staff's telephone calls regarding the Hospice recommendations made on 1/10/24. She said upon assessment, she found that Resident #53 was exhibiting signs and symptoms of severe pain and recommended scheduled Morphine (20 mg/ml) 10 mg (0.5 ml) every 4 hours and to change the prn Morphine to 5 mg (0.25 ml) every 2 hours prn for pain or shortness of breath. Review of the entire medical record on 1/16/24, failed to indicate that Physician #1 addressed the 1/11/24 Hospice recommendation from Hospice Nurse #2 for scheduled Morphine and prn Morphine every 2 hours for pain or shortness of breath. During an interview on 1/17/24 at 10:21 A.M., the Administrator said Physician #1 is especially hard to reach, her voice mailbox is often full and she does not fax over her progress note timely. She said she spoke to Physician #1 last evening at 6:00 P.M. about her delay in responding to Resident #53's Hospice recommendations. She said Physician #1 told her she would do better. During an interview on 1/17/24 at 2:00 P.M., Certified Nursing Assistant (CNA) #2 said she provided care to Resident #53 on 1/9/24, 1/10/24, and 1/12/24. CNA #2 said the Resident was screaming in pain whenever they assisted him/her and she felt so bad for the Resident. During interviews on 1/18/24 at 7:30 A.M., 9:35 A.M. and 3:55 P.M., Physician #1 said that she had received two or three telephone calls from the facility on 1/10/24 and didn't answer them. She said she called sometime later and spoke to a nurse. The physician said she is very busy, works in several buildings and has a private practice and could not recall the date and time she made the telephone call or to whom she spoke. She said if nursing was concerned about her not calling them back, they should have contacted the Medical Director. She said the nurse told her the Resident was in pain only when he/she was provided ADL care. She said she did not agree to the recommendation to increase the dose of pain medication. She said she saw the Resident in person early in the morning on 1/11/24 and said the Resident appeared to be terminal and agreed to increase the dose of Morphine. The Physician could not recall what nursing staff she spoke to on 1/11/24 and could not explain why an order was not written or given verbally for the increased dose of Morphine per Hospice recommendations, but instead sent the order via text to Nurse #1 at 5:52 P.M., and not at the time of her visit. During a subsequent interview with Nurse #1 on 1/18/24 at 3:00 P.M., she said she never saw or spoke with Physician #1 on 1/11/24 while she was in the building and was never given any verbal order to increase Resident #53's dose of Morphine. She said she finally received a text message from Physician #1 at 5:52 P.M., when she was off duty, indicating she agreed to the Hospice recommendation to increase the dose of Morphine. The nurse said she contacted Nurse #12 at the facility to inform her the physician gave a verbal order for Morphine 0.5 ml/10 mg every 4 hours as needed. Nurse #1 said in hindsight, she should have notified the Director of Nursing that Physician #1 was not responding to nursing staffs' calls and messages so the Resident could receive pain relief sooner. After surveyor inquiry, the facility obtained progress notes from Physician #1 for her 1/11/24 visit to Resident #53. Review of the Physician's progress note indicated it was completed on 1/16/24 at 1:05 P.M. and faxed to the facility on [DATE] at 1:56 P.M. Review of the progress note indicated Physician #1 agreed to Hospice recommendations made on 1/10/24 to increase the Morphine to 10 mg every 4 hours. Review of the medical record failed to indicate that Physician #1 made her notes available to facility staff for her visit on 1/11/24 or gave orders to implement the Hospice Nurses' recommendations to increase the Morphine doses. During a telephone interview on 1/19/24 at 12:47 P.M., Nurse #12 said she learned of the Hospice recommendation to increase Resident #53's Morphine dose on 1/10/24 when she came on duty for the 3:00 P.M. to 11:00 P.M. shift. She said she tried calling Resident #53's physician, but there was no answer, and could not leave a message because the voice mailbox was full. Nurse #12 said she took a picture of the Hospice recommendation and sent it to the physician via text on 1/10/24 (she could not remember the exact time) and did not hear anything back throughout her shift. Nurse #12 said the Resident's lungs were getting filled up with fluid, and he/she would cry out in severe pain when the head of the bed was raised or anytime he/she was fed, repositioned, or provided ADL care. Nurse #12 said she came back on duty on 1/11/24 at 3:00 P.M. and was informed the physician had not responded to the Hospice recommendation although several attempts had been made to contact Physician #1. Nurse #12 said she took a picture of the 1/11/24 Hospice recommendation and sent it to the physician on 1/11/24 at 4:12 P.M. Nurse #12 said that sometime after that, she received a telephone call from Nurse #1 informing her that Physician #1 had finally contacted her and approved the 1/10/24 Hospice recommendation for Morphine Sulfate 100 mg/5 ml, give 0.5 ml/10 mg every 4 hours as needed for pain/shortness of breath. Nurse #12 entered the order and administered the first dose on 1/11/24 at 7:30 P.M., more than 24 hours after the initial recommendation by Hospice was made. Physician #1 never addressed the 1/11/24 Hospice recommendation for scheduled Morphine (20 mg/ml) 10 mg (0.5 ml) every 4 hours and to change prn Morphine to 5 mg (0.25 ml) from every 4 hours to every 2 hours prn for pain or shortness of breath that Nurse #12 had sent the physician on 1/11/24 at 4:12 P.M.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had right sided paralysis and was assessed by nursing as requiring one to two staff members to provide physical assistance to safety transfer, the Facility failed to ensure Resident #1 was provided with the appropriate level of staff assistance in an effort to maintain his/her safety and prevent an incident/accident resulting in an injury. On 06/13/21, Certified Nurse Aide (CNA) # 1 went to assist Resident #1 back to bed from his/her wheelchair. CNA #1, who should have been standing in front of the wheelchair next to Resident #1, stood behind Resident #1's wheelchair during a transfer and was therefore not in a position to physically assist him/her during the transfer. When Resident #1 stood up from the wheelchair in an attempt to transfer, his/her body jerked, he/she fell on to the bed, and he/she immediately cried out in pain. Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a right oblique distal femur (thigh bone) fracture with severe posterior dislocation. Findings include: The Facility's Policy titled Clinical Services, Subject: Transfer Technique, dated October 2019, indicated the following: -the Facility would ensure all residents transfers were completed in a safe and efficient manner. -the nurse and/or physical therapist would evaluate and determine lifting and transfer requirements and the procedures to be used for each resident. -all nursing staff were responsible for using good body mechanics and knowing the proper procedures for transfers. Resident #1 was admitted to the Facility in November 2013, diagnoses included severe traumatic brain injury, right sided [CONDITION(S)] (paralysis of one side of the body), Dysphasia, and [CONDITION(S)]. Review of Resident #1's Licensed Monthly Summary, dated 05/23/22, indicated he/she required assistance from two staff member for transfers. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive physical assistance from two staff members for transfers. Review of Resident #1's Plan of Care related to activities of daily living (ADL), dated as initiated 07/05/18 and reviewed/revised on 06/17/22, indicated he/she had physical performance deficits due to a traumatic brain hemorrhage, lack of coordination, muscle weakness, and right-side [CONDITION(S)]. Further review of Resident #1's POC indicated he/she required physical assistance to total dependence of one to two staff members for transfers, and that his/her level of assistance fluctuated based on Resident #1's behaviors. Review of the Facility's Internal Investigation, dated 06/17/22, indicated that on 06/13/22 at approximately 6:25 P.M., CNA #1 assisted Resident #1 with a transfer from his/her wheelchair into his/her bed. The Investigation indicated that CNA #1, positioned Resident #1's wheelchair alongside the bed, close enough for Resident #1 to reach the side rail with his/her left hand, and stand on his/her left leg to pivot into bed, to assist with the transfer onto the bed. The Investigation indicated Resident #1 jerked onto the bed and then he/she cried out in pain. The Investigation indicated Resident #1 was transferred to the Hospital Emergency Department and was diagnosed with a right oblique distal femur fracture with severe posterior dislocation. During an interview on 06/29/22 at 3:07 P.M., the Director of Rehabilitation Services, the Physical Therapist (PT) and Occupational Therapist (OT) said that for Resident #1 to be transferred safely, he/she required physical assistance from a staff member. The Director, the PT and the OT said the staff member needed to be positioned in front of Resident #1 as he/she transferred from a wheelchair and into bed. The Director, the PT and the OT said the staff member should not be standing behind Resident #1's wheelchair during a transfer, because they would not be in a position to physically assist Resident #1 during the actual transfer. Review of CNA #1's Written Witness Statement, dated 06/13/22, indicated that she assisted Resident #1 into bed, like she always did. The Statement indicated she (CNA #1) was standing behind Resident #1's wheelchair to support him/her during the transfer. The Statement indicated Resident #1 grabbed the side rail, then jumped to the bed, and then Resident #1 yelled out words to the effect of operation, operation, hurt, hurt. During an interview on 06/29/22 at 10:05 A.M., CNA #1 said that when she assisted Resident #1 with transfers, she always used the same transfer technique as she had used on 06/13/22. CNA #1 said she was standing behind Resident #1's wheelchair when he/she was transferring out of the wheelchair. CNA #1 said Resident #1 sort of jumped as he/she transferred into bed. CNA #1 said she went to swing Resident legs into bed when he/she yelled out in pain. CNA #1 said Resident #1 was wearing a hospital gown and she could see his/her leg beginning to swell, so she moved Resident #1 from a sitting to a lying position, and then went to Resident #1's bedroom doorway to call for a nurse. During an interview on 06/29/22 at 3:20 P.M., the Director of Nursing said they (Administrative staff) did not speak with staff members from the rehabilitation department as part of their investigation regarding the transfer techniques CNA #1 used on 06/13/22, when Resident #1 sustained a fracture.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had right sided paralysis and was assessed by nursing as requiring physical assistance of one to two staff members for transfers, the Facility failed to ensure interventions identified in his/her plan of care related to the need for physical assistance during a transfer was appropriately implemented by staff. On 06/13/22, Certified Nurse Aide (CNA) #1 was not positioned correctly in order to physically assist and help facilitate a safe transfer for Resident #1 and remained behind Resident #1, in back of his/her wheelchair during the transfer. CNA #1 should have been standing in front of Resident #1, therefore putting herself is a position to provide actual physical assistance as Resident #1 transferred out of the wheelchair. During the transfer Resident #1's body jerked, he/she fell on to the bed, and then cried out in pain. Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a right oblique distal femur (thigh bone) fracture with severe posterior dislocation. Findings include: The Facility's Policy titled, Clinical Services, Subject: Baseline/Comprehensive Person-Centered Care Plan, dated October 2017, indicated the following: - resident comprehensive person center care plans (CPCCP) would be developed after the completion of the comprehensive assessment, - CPCCP would be reviewed by an interdisciplinary team that included the following representatives: Specialized Rehab. -Facility would periodically review and revise the CPCCP based on the MDS assessments and reassessments and upon any changes in status. The Facility's Policy titled Clinical Services, Subject: Transfer Technique, dated October 2019, indicated the following: - the Facility would ensure all residents transfers were completed in a safe and efficient manner. - the nurse and/or physical therapist would evaluate and determine lifting and transfer requirements and the procedures to be used for each resident. - all nursing staff were responsible for using good body mechanics and knowing the proper procedures for transfers. Resident #1 was admitted to the Facility in November 2013, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Licensed Monthly Summary, dated 05/23/22, indicated he/she required assistance from two staff member for transfers. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive physical assistance from two staff members for transfers. Review of Resident #1's Plan of Care (POC) related to activities of daily living (ADL), dated as initiated on 07/05/18, reviewed and revised on 06/17/22, indicated he/she had physical performance deficits due to a traumatic brain hemorrhage, lack of coordination, muscle weakness, and right-side [CONDITION(S)]. Further review of Resident #1's POC indicated he/she required physical assistance to total dependence of one to two staff members for transfers, and his/her level of assisted fluctuated based on his/her behaviors. Review of the Facility's Internal Investigation, dated 06/17/22, indicated that on 06/13/22, at approximately 6:25 P.M., CNA #1 went to assist Resident #1 with a transfer from his/her wheelchair into his/her bed. The Investigation indicated that CNA #1, positioned Resident #1's wheelchair alongside the bed, close enough for Resident #1 to reach the side rail with his/her left hand, and stand on his/her left leg to pivot into bed, to assist with the transfer onto the bed. The Investigation indicated Resident #1 jerked, fell on to the bed, and then he/she cried out in pain. The Investigation indicated Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a right oblique distal femur fracture with severe posterior dislocation. Review of the Facility's Fall Data Collection Tool, dated 06/13/22, indicated Resident #1, who had expressive aphagia, yelled words to the effect of, Operation, Ow, Ow, Ow. The Tool indicated that Resident #1 fell into bed during a transfer from his/her wheelchair. During an interview on 06/29/22, at 3:07 P.M., the Director of Rehabilitation Services, the Physical Therapist (PT) and Occupational Therapist (OT) said that for Resident #1 to be transferred safely, Resident #1 required physical assistance from a staff member, and they said the staff member(s) should position him/herself in front of Resident #1 as he/she is transferred from a wheelchair and into bed. The Director, PT and OT said the staff member(s) should not be standing behind Resident #1's wheelchair during a transfer, because from that position, the staff member would not be in a position to physically assist Resident #1 with the transfer. Review of Resident #1's Hospital Consult Note, dated 06/14/22, indicated that Resident #1 presented to the Hospital for a right oblique distal femur fracture with severe posterior dislocation after a fall during a transfer at the Facility. Review of CNA #1's Written Witness Statement, dated 06/13/22, indicated that she assisted Resident #1 into bed, like she always did, that she (CNA #1) was standing behind Resident #1's back to support him/her during the transfer. The Statement indicated Resident #1 grabbed the side rail, then jumped to the bed, and yelled words to the effect of operation, operation, hurt, hurt. During an interview on 06/29/22 at 10:05 A.M., Certified Nurse Aide (CNA) #1 said that when she assisted Resident #1 with transfers, she always used the same transfer techniques as she had used on 06/13/22. CNA #1 said she was standing behind Resident #1's wheelchair as Resident #1 sort of jumped as he/she transferred into bed. CNA #1 said she then went to help swing Resident #1's legs into bed when he/she yelled out in pain. CNA #1 said Resident #1 was wearing a hospital gown and she could see his/her leg beginning to swell, so she moved Resident #1 from a sitting to a lying position, and went to Resident #1's bedroom doorway to call for a nurse. During an interview on 06/29/22 at 3:20 P.M., with the Director of Nursing (DON) said, as part of their internal investigation, they (Administrative staff), did not speak with staff members from the rehabilitation department regarding the transfer techniques CNA #1 used on 06/13/22, when Resident #1 sustained a fracture.

Based on record review, observation and staff interview, the facility failed to provide adaptive equipment for one Resident (#4) according to the plan of care in a sample of 16 Residents. Findings include: 1. For Resident #4, the facility failed to provide adaptive equipment to maintain activity of daily living skills for eating and to avoid potential complications. Resident #4 was admitted to the facility in 2/2013 with multiple medical conditions that included [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment completed 7/3/14, indicated Resident #4 was alert and oriented, required assistance for activities of daily living (ADL) with use of adaptive equipment, and fed him/herself independently. The Resident was at risk for skin impairment, on a pain management regime and required [MEDICAL TREATMENT] treatments three time per week. Review of the Resident's plan of care dated 7/3/14, for self care ADL deficits, indicated a goal to maintain self performance and not develop any complications related to decreased ADL performance. Care approaches included to provide adaptive safety equipment; provide only the amount of supervision and assistance that is needed; to provide built up eating utensils, a blue insulated mug for safety (Kennedy cup/lid) and lip plate at meal times and invite, encourage escort to activities of interest. The nurse's note dated 9/13/14, indicated the Resident had suffered an abdomen burn earlier in the day from a coffee spill. The note indicated the Resident had no complaints of pain and the area was .5 by 1 centimeters in size. An interim telephone order dated 9/13/14, was obtained to treat the Resident's mid-abdomen with [MEDICATION NAME] and cleanse with normal saline. A physician progress notes [REDACTED]. During interview on 9/15/14 at 1:15 P.M., the Resident said that during morning coffee on the weekend that someone bumped him/her and the hot coffee spilled. The skin area was sore, if it was touched but alright. Observation on 9/15/14 at the noon meal and on 9/16/14 at 5:15 P.M. for the evening meal service, the Resident's dining meal place settings included adaptive built up eating utensils, lip plate and beverage mugs (Blue Insulated mug/cover, also known as Kennedy cup). Review of the activity cart booklet on 9/16/14, had included residents' dietary and adaptive equipment needs such as blue insulated mug with cover for Resident #4. Review of the facility's investigation of the incident provided for review on 9/18/14, indicated that during a 9/13/15 morning activity coffee social, the Resident was given a cup of coffee in a regular mug and not the insulated blue mug with a cover. During interview on 9/18/14 at 9:00 A.M., the Director of Nurses said she did not know why the activity staff did not follow the care plan.

Based on observations and staff interviews, the facility failed to ensure the residents environment was free of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents for 1 Resident (#4) in a sample of 16 Residents. The facility failed to ensure that oxygen and equipment storage was maintained in a safe manner to avoid potential accidents and according to proper local fire prevention codes. Findings include: 1. For Resident #4, the facility failed to provide adaptive equipment to maintain activity of daily living skills for eating resulting in a second degree burn. Resident #4 was admitted to the facility in 2/2013 with multiple medical conditions that included [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment completed 7/3/14, indicated Resident #4 was alert and oriented, required assistance for activities of daily living (ADL) with use of adaptive equipment, and fed self independently. The Resident was at risk for skin impairment, on a pain management regime and required hemodialysis treatments three time per week. Review of the Resident's plan of care dated 7/3/14, for self care ADL deficits, indicated to maintain self performance and not develop any complications related to decreased ADL performance. Care approaches included to provide adaptive safety equipment; provide only the amount of supervision and assistance that is needed; to provide built up eating utensils, blue insulated mug with cover (Kennedy cup) and lip plate at meal times and invite, encourage escort to activities of interest. The nurse's note dated 9/13/14, indicated the Resident had suffered an abdomen burn earlier in the day from a coffee spill. The note indicated the Resident had no complaints of pain and the area was .5 by 1 centimeters in size. An interim telephone order dated 9/13/14, was obtained to treat the Resident's mid-abdomen with Silvadene and cleanse with normal saline. A physician progress notes [REDACTED]. During interview on 9/15/14 at 1:15 P.M., the Resident said that during morning coffee on the weekend that someone bumped him/her and the hot coffee spilled. The skin area was sore, if it was touched but alright. Observation on 9/15/14 at the noon meal and on 9/16/14 at 5:15 P.M. for the evening meal service, the Resident's dining meal place settings included adaptive built up eating utensils, lip plate and beverage mugs (Kennedy cup, Blue Insulated mug / cover). Review of the activity cart booklet on 9/16/14, had included residents' dietary and adaptive equipment needs such as blue insulated mug for Resident #4. Review of the facility's investigation of the incident provided for review on 9/18/14, indicated that during a 9/13/15 morning activity coffee social, the Resident was given a cup of coffee in a regular mug and not the insulated blue mug with a cover. 2.Storage sheds were noticed located just outside the East nursing unit, as nursing staff left the unit to remove extra equipment. The outside storage units included three free standing sheds. A metal shed storage unit that included signage (10 inch high by 3 inch wide) for oxygen, with a symbol of a cigarette crossed to indicate no smoking. The metal shed had a pad lock that was broken with doors that did not close properly to secure the contents. Inside this metal shed the facility stored seven portable oxygen tanks, three portable oxygen concentrators and two liquid oxygen compressors tanks. The environment of this metal shed was unclean and evidenced two extinguished cigarette butts on the interior shed flooring. In direct vicinity to this shed was evidence of discarded cigarette butts on the ground outside the shed. During interview on 9/17/14 at 11:00 A.M., the Unit Manager #1 said that staff utilize the shed to refill residents' portable oxygen tanks. A large open can used for cigarette butt disposal was also seen on the ground just outside this East unit exit door and within 25 feet of this oxygen storage shed and an adjacent wooden storage shed. During interview on 9/17/14 at 3:35 P.M., the Administrator said that the facility was a non smoking residence and was not aware of any outside designated smoking areas. When asked where do staff smoke, the Administrator said that upon hire, employees are provided with an employee handbook that states that the facility is smoke free and that smoking is prohibited anywhere inside the facility and in any other locations where a No Smoking sign is posted. Observations on 9/17/14 at 11:00 A.M. revealed open can of cigarette butts near the wooden shed and oxygen storage shed, there were at least two other areas with cigarette butts discarded in an open can near the laundry and lower level delivery area, and service corridor exit off the kitchen and at the far end of the East nursing unit. Further interview on 9/17/14 at 3:35 P.M., the Administrator was not aware of the facility's oxygen storage policy or the arrangement between the oxygen supply company and the facility. On 9/18/14 at 11:40 A.M., the Administrator said that the facility did not have an oxygen storage policy.

Based on record review and interviews, for one of seven sampled residents (Resident #1), the Facility failed to ensure that Resident #1's safety alarm was attached, per plan of care, when Resident #1 was in bed.. On 8/9/12 at approximately 2:00 A.M. Certified Nurse Aide #1 left Resident #1 in bed on his/her left side and did not attach the safety alarm. Resident #1 was found on the floor at approximately 2:30 A.M. with a laceration to his/her right ear, which required 6 sutures to close the wound. Findings include: Resident #1 was admitted to the Facility June of 2007, and [DIAGNOSES REDACTED]. The plan of care, dated 5/1/10, indicated that Resident #1 was at risk for falls related to [DIAGNOSES REDACTED], stiffness, and poor safety awareness. Plan of care interventions included a low bed, a personal (clip) alarm in the wheelchair, and a bed pad safety alarm while in bed. The physician's orders [REDACTED].#1 at all times. The resident care card indicated that Resident #1 required a bed alarm for safety. The annual Minimum Data Set (MDS) assessment, dated 5/10/12, indicated that Resident #1: required total care of the nursing staff for bed mobility, dressing, eating, and toilet use; he/she was unable to ambulate in corridor or room, and he/she was incontinent of bowel and bladder. The nurse's note, dated 8/9/12, for the 11:00 P.M. to 7:00 A.M. shift (no time documented), indicated that Resident #1 fell out of bed, the fall was unwitnessed, and Resident #1 sustained a right ear laceration and bleeding to the right ear. The nurse's note indicated that Resident #1 had a skin tear to the right elbow, Resident #1 was assessed and stabilized, and the Physician was notified of the fall. The nurse's note indicated that Resident #1 was transferred to the Hospital at approximately 3:30 A.M. The Surveyor interviewed the Director of Nurses (DON) on 10/17/12 at 8:46 A.M. and on 10/22/12 at 1:45 P.M. The DON said Resident #1's plan of care included a personal clip alarm when in bed. The CNA care card indicated that Resident #1 had an alarm in bed. The DON said CNA #1 failed to reattach the clip alarm after she provided incontinence care to Resident #1 at approximately 2:00 A.M. The DON said CNA #1 told her she observed a soiled dressing on Resident #1, left Resident #1 on his/her left side in bed to inform Nurse #1 that Resident #1's dressing was soiled, but failed to reattach the clip alarm before leaving Resident #1's room. The DON said CNA #1 said Resident #1 was found on the floor at approximately 2:30 A.M. The Surveyor called CNA #1 to request an interview but the telephone number provided was no longer in service. The internal investigation statement, written by CNA #1 and dated 8/9/12, indicated that CNA #1 performed incontinence care for Resident #1 at approximately 2:00 A.M., his/her dressing was soiled, and CNA #1 removed the dressing. The statement indicated that CNA #1 positioned Resident #1 on his/her left side, pulled up the 1/4 side rail, and notified Nurse #1 about the soiled dressing. The investigation statement indicated that CNA #1 said she forgot to re-attach Resident #1's personal alarm and when she returned in approximately one minute, Resident #1 was on the floor with his/her head against the nightstand. The statement indicated that CNA #1 called for help and Nurse #1 came into Resident #1's room. The Surveyor interviewed Nurse #1 on 10/17/12 at 2:00 P.M. Nurse #1 said he worked on the 11:00 P.M. to 7:00 A.M. shift on 8/9/12. Nurse #1 said it was difficult to remember exact times, but during second rounds, CNA #1 notified him that Resident #1's dressing needed to be changed. Nurse #1 said he checked the treatment book prior to getting the supplies and a few minutes later, CNA #1 told him Resident #1 was on the floor. Nurse #1 said he immediately went to Resident #1's room, assessed his/her airway, and observed a laceration to Resident #1's right ear. Nurse #1 said he notified the Physician, provided first aid to Resident #1, and Resident #1 was stabilized on the ground until the ambulance (911)arrived to transport Resident #1 to the Hospital. The Hospital emergency room report and interagency referral form, dated 8/9/12, indicated that Resident #1 was treated for [REDACTED].