Every finding on record at Country Gardens Health and Rehabilitation

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing staff notified his/her Health Care Agent (HCA), that he/she had changes in his/her condition which also included the need for new Physician's orders.Findings include:Review of the Facility's Policy titled Change in a Resident's Condition or Status, dated May 2023, indicated the following:-our facility shall promptly notify the resident's representative of change in the resident's medical/mental condition and/or status.-the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During an interview on 09/09/25 at 10:42 A.M., Family Member #1 (who was Resident #1's HCA) said Resident #1 was re-admitted to the facility on [DATE], after a hospitalization. Family Member #1 said she called the facility on 07/04/25 to see how Resident #1 was doing and said she was told everything was fine, that he/she was doing okay. Family Member #1 said she was not notified by nursing that he/she required a diet change or that Resident #1 had a blister on his/her right heel.Family Member #1 said she also found out that Resident #1 had a vasovagal episode on 07/23/25 while working with therapy, that he/she became unresponsive for a period of time and said the facility had also not notified her of that event.Family Member #1 said it was not until after she had requested and reviewed a copy of Resident #1's medical record (sometime around the end of July 2025), that she became aware the incidents or/and changes that had occurred.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 02/01/24, indicated that Resident #1's Health Care Proxy (HCP) was permanently invoked.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/24/25, indicated that he/she had moderate impaired cognition.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 was evaluated by Speech Pathology, he/she was determined to be at risk for aspiration (inhalation of food, fluid or other foreign material into the lungs) and received a Dysphagia (difficulty swallowing foods or liquids) Carbohydrate (CHO) Consistent soft/easy to chew with thin liquids diet during his/her hospitalization. The Summary indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident had an empty fluid blister on his/her right heel, orders were confirmed with the Nurse Practitioner who gave a new order for skin prep three times a day and to offload his/her right heel on pillow while in bed.Review of Resident #1's medical record indicated there was no documentation to support his/her HCA was notified.During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.However, review of Resident #1's Diet Requisition Form indicated it was not completed until 07/07/25 and included that he/she was a re-admission with a diet change. The Form indicated the diet order was for a Dysphagia Advanced texture diet.Nurse #1 also said upon Resident #1's return to the facility that day, he/she had a fluid blister on his/her right heel, and the NP gave an order for skin prep and to offload his/her right heel on a pillow while in bed. Nurse #1 said she did not notify Resident #1's HCA of his/her return from the hospital, or that he/she had a new treatment order to his/her right heel and said she should have.Review of Resident #1's Nurse Progress Note, dated 07/23/25 (written by Former Unit Manager), indicated that Resident #1 became unresponsive to verbal and tactile stimuli while with Rehabilitation. The Note indicated that he/she was put into bed, his/her vitals and blood sugar were taken, legs were elevated, and he/she became responsive to tactile stimuli. The Note further indicated that the NP was notified and ordered STAT (immediately) bloodwork, a urinalysis (UA) and a culture and sensitivity (C&S).Review of Resident #1's Physician Progress Note, dated 07/24/25, indicated that Resident #1 was evaluated after an episode of unresponsiveness, likely vasovagal in origin.During an interview on 09/15/25 at 4:48 P.M., the Former Unit Manager said Resident #1 became unresponsive while working with therapy (could not recall exact date) and she notified the NP and obtained new orders for lab work, UA and C&S. The Former Unit Manager said she could not recall if she notified Resident #1's HCA that day of his/her episode.Further review of Resident #1's medical record indicated there was no documentation to support that the facility ever notified Family Member #1 (HCA) related to Resident #1's new diet order, new treatment order to his/her right heel, and that he/she had experienced a vasovagal event and Physician orders for lab work were obtained.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1's HCA had not been notified of his/her changes and said all nurses should have followed the facility's policy.During an in-person interview on 09/10/25 at 4:06 P.M and a telephone interview on 09/16/25 at 2:46 P.M., the Director of Nursing (DON) said it is her expectation that all nurses should notify resident's family, responsible person, or HCA of changes in their status or condition.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose hospital discharge summary indicated he/she required an altered textured diet (dysphagia diet), the Facility failed to ensure meals prepared and served to him/her met his/her individual need, when his/her new diet orders were not transcribed by nursing, and he/she received the incorrect diet for two days. Findings Include: Review of the Facility's Policy tilted Therapeutic Diet Orders Policy, dated as reviewed/revised March 2025, indicated the following: -the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician.-a Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake.-all diet orders are to be communicated to the dietary department in accordance with facility procedures.-dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the Facility's Policy titled Charting and Documentation, dated May 2023, indicated the following: -all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.-documentation in the medical record will be complete and accurate.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 was evaluated by Speech Pathology, he/she was determined a risk for aspiration (inhalation of foods, fluids, or other foreign objects into the lungs) and received a Dysphagia (difficulty swallowing or chewing) Carbohydrate (CHO) Consistent soft/easy to chew with thin liquids diet during his/her hospitalization. The Summary indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's previous Physician's Orders, dated as initiated 03/31/25, indicated his/her diet orders were for a Carbohydrate Consistent Diet (CCD) Regular texture with thin liquids consistency and upon re-admission on [DATE], he/she continued to receive that same diet. Further review of the Physician orders indicated that he/she was started on a CCD Dysphagia Advanced texture diet with thin liquids on 07/07/25, three days after being re-admitted .Review of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident #1 was readmitted to the facility and the kitchen was notified to resume his/her previous diet (CCD Regular texture).During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and that he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders, verified all orders with the Nurse Practitioner and entered the orders into Point Click Care (PCC) computer system. Nurse #1 said she notified the kitchen to resume Resident #1's previous diet order which was a CCD Regular texture thin liquids diet. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.During an interview on 09/15/25 at 4:48 P.M., Nurse #4 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25 and was assigned to Resident #1. Nurse #4 said during change of shift report the 11:00 P.M. to 7:00 A.M. Nurse told her that Resident #1 was on a modified ground diet. Nurse #4 said she did not recall that Resident #1 was on a ground diet, and said she checked Resident #1's tray and the kitchen had sent him/her a regular texture diet.Nurse #4 said she reviewed Resident #1's Hospital Discharge paperwork and saw that he/she diet was supposed to be on a Dysphagia Advanced diet. Nurse #4 said she filled out a diet requisition form for Resident #1's new textured diet order and said she gave the form to the Food Service Director and waited for Resident #1's breakfast tray with the correct diet order.However, review of Resident #1's Diet Requisition Form, which was completed and dated 07/07/25, indicated that he/she was a re-admission with a diet change. The Form indicated the diet order was for a Dysphagia Advanced texture diet.During an interview on 09/17/25 at 11:19 A.M., the Food Service Director (FSD) said on 07/07/25 she received a diet requisition form for Resident #1's new diet order for a Dysphagia Advanced diet that morning from one of the nurses. The FSD said Resident #1 received a Regular texture diet on 07/05/25 and 07/06/25 because the kitchen had not been informed of his/her new diet order until the morning of 07/07/25.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1 had a new diet order when he/she returned from the hospital on [DATE] and that he/she had not received the correct diet for two days. The Former DON said two nurses should have reviewed all of Resident #1's orders on his/her Hospital Discharge Summary to ensure that there were no errors made.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had new diet order instructions, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing staff failed to transcribe his/her new diet order onto Resident #1's Physician orders.Findings Include:Review of the Facility's Policy titled Charting and Documentation, dated May 2023, indicated the following:-all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.-documentation in the medical record will be complete and accurate.Resident #1 was admitted to the Facility in January 2024, diagnoses included Dementia, bipolar disorder, type II diabetes mellitus, Parkinson's disease, hypertension, and hyperlipidemia (high cholesterol).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1's discharge diet instructions were for a Dysphagia Carbohydrate Consistent 1600-2000 calories (60-75 grams (g) CHO), soft/easy to chew with thin liquids.Review of Resident #1's Physician's Orders, dated 07/04/25 through 07/07/25, indicated that he/she had orders for a Carbohydrate Consistent Diet (CCD) Regular texture with thin liquidsReview of Resident #1's Nurse Progress Note, dated 07/04/25 (written by Nurse #1), indicated that Resident #1 was readmitted to the facility and the kitchen was notified to resume his/her previous diet (CCD Regular texture).During an interview on 09/10/25 at 2:23 P.M., Nurse #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 07/04/25, was assigned to Resident #1 and that he/she had returned from the hospital that afternoon. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork including all medication, treatments and diet orders, and said that she verified all orders with the Nurse Practitioner and entered the orders into Point Click Care (PCC) computer system. Nurse #1 said she notified the kitchen to resume Resident #1's previous diet order which was a CCD Regular texture thin liquids diet. Nurse #1 said she was not aware that Resident #1 had a new order for a Dysphagia diet and thought she had reviewed all his/her orders but must have overlooked the new diet order.During an interview on 09/16/25 at 1:42 P.M., the Former Director of Nursing (DON) said she was not aware that Resident #1 had a new diet order when he/she returned from the hospital on [DATE] and that Nurse #1 had not transcribed his/her new diet order. The Former DON said two nurses should have reviewed all of Resident #1's orders on his/her Hospital Discharge Summary to ensure that there were no errors made.During an in-person interview on 09/10/25 at 4:06 P.M and a telephone interview on 09/16/25 at 2:46 P.M., the Director of Nursing (DON) said it is her expectation that all nurses should be reviewing all orders on resident's discharge paperwork to ensure no orders are missed.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for: -Failed to Submit Data for the Quarter (No Data Submitted for Quarter) -One Star Staffing Rating (Staff Staffing Rating Equals 1) During an interview on 6/18/25 at 9:37 A.M., the Director of Operations said the company had a change in the corporate Human resource position at the time of PBJ submission for Quarter 2 and they were unaware that the submission had not taken place. He said he attempted to reach out to CMS so they could submit the data after the fact but was informed that wouldn't be possible. He said the PBJ information should have been submitted as required and was not.

3. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: -Staff shall follow established facility infection control procedures for the administration of medications. On 6/16/25 at 8:25 A.M., the surveyor observed Nurse #4 prepare 10 medications for Resident #8. Nurse #4 dropped one pill on to the top of the medication cart, picked up the pill, placed it into the medication cup and administered it to Resident #8. During an interview on 6/16/25 at 8:43 A.M., Nurse #4 said she had cleaned the top the of the medication cart at the beginning of her shift at 7:00 A.M. and the pill had not fallen on the floor but on top of the medication cart. During an interview on 6/16/25 at 4:25 P.M., the Director of Nursing said Nurse #2 should not have administered the medication after it fell on top of the medication cart. The Director of Nursing said the top of the medication is not considered a clean surface and if a medication falls on top of the medication cart it should be disposed of and a new pill should have been administered as it is an infection control concern. Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Ensure contact tracing and outbreak testing were completed on two occurrences in February 2025; and 3. Ensure that sanitary practices were used by nursing while preparing and administering medications. Findings include: 1. Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated, but was not limited to, the following: -An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. -Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. -Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. -Outbreak management is a process that consists of: 1) determining the presence of an outbreak; 2) managing the affected residents; 3) preventing the spread to other residents; 4) documenting information about the outbreak 5) reporting the information to appropriate public health authorities; 6) educating the staff and the public; 7) monitoring for recurrences; 8) reviewing the care after the outbreak has subsided; 9) recommending new or revised policies to handle similar events in the future. -Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. Review of an untitled and undated facility policy indicated, but was not limited to, the following: -It is the policy of this facility to complete Infection Control Line Listings each month. The data on the line listings will be used to identify improvement opportunities. These line listings will be utilized to produce a roll up of data that will be reviewed for improvement opportunities. -Line Listing will include - *Resident Name or Identifier *Room # *Category of Infection *Date of Onset *Symptoms *Date of Culture *Site of Infection *Results of Culture *Treatment - including name of ABX (antibiotic) used *Date Infection cleared *Final Status - HAI (healthcare-acquired infection) or CAI (community-acquired infection) -These listing [sic] will be entered into a standardized spreadsheet that will provide a breakdown and comparison of data. The report will look at Infection trends over a period of time. Review of the facility's infection surveillance line listings indicated, but was not limited to, the following: July 2024 -8 out of 8 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 1 blood infections failed to include culture results identifying the organism/bacteria -Review of the Infection Control Report provided by the facility's consultant laboratory indicated that a urine specimen collected from a resident on 7/27/24 resulted positive for ESBL (extended-spectrum beta-lactamase producing bacteria - bacteria that produce enzymes that break down certain antibiotics, making them ineffective). This culture result was not included on the facility's July 2024 line listing document. August 2024 -9 out of 9 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 2 urinary tract infections failed to include culture results identifying the organism/bacteria September 2024 -2 out of 7 resident infections had no documented site/type of infection -7 out of 7 resident infections had no documented signs and symptoms of an illness or date of symptom onset October 2024 -6 out of 6 resident infections had no documented signs and symptoms of an illness or date of symptom onset -Review of the Infection Control Report provided by the facility's consultant laboratory indicated that a urine specimen collected from a resident on 10/3/24 resulted positive for Proteus penneri (a type of bacteria associated with healthcare-acquired infections). This culture result was not included on the facility's October 2024 line listing document. November 2024 -10 out of 10 resident infections had no documented signs and symptoms of an illness or date of symptom onset December 2024 -11 out of 11 resident infections had no documented signs and symptoms of an illness or date of symptom onset -1 out of 6 urinary tract infections failed to include culture results identifying the organism/bacteria No facility surveillance line listings were provided to the surveyor for the months of January 2025 through May 2025. The facility's Infection Prevention Nurse provided the surveyor with Infection Control Reports from the consultant laboratory with resident culture results and monthly Order Listing Reports from the facility's electronic health record (EHR) with a list of antibiotics prescribed each month. The Order Listing Reports and Infection Control Reports failed to include dates of symptom onset and signs and symptoms of infection present. Additionally, the reports failed to include laboratory results from specimens collected outside of the facility. Further review of the Infection Control Reports provided by the facility's consultant laboratory indicated the Reports for July 2024 through February 2025 were not generated until April 2025. Further review of the facility's line listings failed to indicate that suspected infections that were not treated with antibiotics, such as suspected gastrointestinal or urinary tract infections with negative culture results, were included on the facility's infection surveillance line listings. During an interview on 6/18/25 at 2:04 P.M., the Infection Prevention Nurse said she uses the facility's EHR generated report of residents that have been prescribed antibiotics each month and the Infection Control Report generated by the facility's consultant laboratory as her monthly infection surveillance logs. The Infection Prevention Nurse said the EHR and laboratory reports do not include a description of symptoms, symptom onset date, tracking of suspected infections not treated with antibiotics, or culture results from laboratories outside of the facility's consultant laboratory. The Infection Prevention Nurse said she had used a handwritten line listing tool through December 2024 and tried an electronic spreadsheet for infection surveillance before switching to the EHR and laboratory reports. The Infection Prevention Nurse said symptoms and laboratory results should be included as part of the infection surveillance program. During an interview on 6/23/25 at 7:39 A.M., the Director of Nursing said the facility's line listings should include date of onset and signs and symptoms of infection. 2. Review of the facility's policy titled Infection Prevention and Control COVID-19, revised 6/30/23, indicated, but was not limited to, the following: -An outbreak investigation is initiated when a new nursing home onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). -The Infection Preventionist will conduct ongoing surveillance for all Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections such as COVID-19 that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. -The Infection Preventionist, or designee, will be responsible for the following protocols for contact tracing: *Identify residents, employees, and visitors who the confirmed positive case had contact with the 48 hours prior or 10 days following the positive test or symptoms. -Outbreak Testing *Document the date the case was identified, the date that other residents and staff are tested, the date that all residents and staff who tested negative are retested, and results of all tests. *Staff test results may be maintained on a log in a secure location. Review of the facility's line listings indicated that a resident on the [NAME] unit tested positive for COVID-19 on 9/28/24. Subsequently, 14 additional residents on the [NAME] unit tested positive for COVID-19 between 10/1/24 and 10/25/24. The surveyor requested documentation of the facility's outbreak investigation, including contact tracing and outbreak testing logs for staff and residents. The Infection Prevention Nurse provided the surveyor with a line listing of COVID-19 positive residents. The line listing failed to include information on the residents' signs/symptoms of COVID-19 and date of symptom onset. The facility failed to provide the surveyor with a list of who had been exposed to COVID-19 positive residents and when they were tested. During an interview on 6/18/25 at 2:04 P.M., the Infection Prevention Nurse said the facility had no infectious disease outbreaks since the previous survey in July 2024. During an interview on 6/23/25 at 12:20 P.M., the Infection Prevention Nurse said the facility did have an outbreak of COVID-19 in October 2024. The Infection Prevention Nurse said she had no additional outbreak investigation documentation other than what was included on the line listing of COVID-19 positive residents provided to the surveyor. The Infection Prevention Nurse said residents on the [NAME] unit were tested every 48 hours until seven days passed with no new cases of COVID-19 identified and results were documented in each resident's medical record. The Infection Prevention Nurse said staff were tested before reporting to the unit for their shift during the outbreak period, but the facility did not keep documentation of staff testing dates and/or test results. The Infection Prevention Nurse said she kept a list of the COVID-19 positive residents, but did not maintain documentation of any contact tracing or additional outbreak investigation information.

Based on personnel record review and interview, the facility failed to ensure the new hire employee records contained evidence of the 2024-2025 COVID-19 vaccination for four of five newly hired employees. Specifically, the facility failed to ensure the employee record contained evidence of the 2024-2025 COVID-19 vaccination or proof the newly hired employees were offered an updated COVID-19 vaccine when he/she was eligible. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance, Staying up to date with COVID-19 vaccinations, dated as revised June 6, 2025, indicated but was not limited to the following: - CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 years and older. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. Importance of staying up to date: - Getting the 2024-2025 COVID-19 vaccine is important because protection from the COVID-19 vaccine decreases with time; Immunity after COVID-19 infection decreases with time; COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. - Administer recommended vaccines if vaccination history is incomplete or unknown. - Routine vaccination: age [AGE]-64 years: a. Unvaccinated: 1 dose 2024-25 Moderna or Pfizer-BioNTech; 2 doses 2024-25 Novavax at 0, 3-8 weeks b. Previously vaccinated before 2024-25 vaccine with: 1 or more doses Moderna or Pfizer-BioNTech: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 dose Novavax: 1 dose 2024-25 Novavax 3-8 weeks after most recent dose. If more than 8 weeks after most recent dose, administer 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. 2 or more doses Novavax: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 or more doses [NAME]: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. - Routine Vaccination: age [AGE] years and older: a. Unvaccinated: follow recommendations above for unvaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months). b. Previously vaccinated before 2024-25 vaccine: follow recommendations above for previously vaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months). - Unvaccinated persons have never received any COVID-19 vaccine doses. There is no preferential recommendation for the use of one COVID-19 vaccine over another when more than one recommended age-appropriate vaccine is available. Administer an age-appropriate COVID-19 vaccine product for each dose. Staff member #1 was hired on 6/3/25 as a Nurse. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #3 was hired on 2/19/25 as an Activity assistant. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #4 was hired on 5/6/25 as a Nurse. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Staff member #5 was hired on 3/19//25 as a Maintenance assistant. Review of the employee file failed to indicate that the facility had offered the new employee the most recent COVID-19 vaccination to assist in protecting themselves against COVID-19. Review of the employee timecards indicated that the four new hires, who had not been offered the most recent COVID-19 vaccination, had been actively working in the facility. During an interview on 6/23/25 at 8:32 A.M., the Human Resource (HR) staff at the facility said he provides a list to new employees prior to hire of items they need to bring in with them at the time of orientation, including current vaccination with the COVID-19 vaccine. He said he does not confirm whether or not the files contain an offer of the current COVID-19 vaccination once he receives the information back from the Infection Preventionist (IP) because he was unaware that the facility was required to offer its staff the most recent COVID-19 vaccination. During an interview on 6/23/25 at 9:03 A.M., the IP said the facility has newly hired staff bring a copy of their vaccine history with them at the time of hire, which includes the COVID-19 vaccination and information should be in the employee files. She said the staff should have a signed declination or consent on file if they choose to receive the newest vaccine. During an interview on 06/23/25 at 2:41 P.M., the IP said the facility does not offer COVID-19 vaccination or boosters to new staff upon hire and that is why no documentation could be located in the employee files.

4. Resident #8 was admitted to the facility in January 2024 with diagnoses including migraine (a neurological condition that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head, accompanied by nausea, vomiting, and extreme sensitivity to light and sound) and restless leg syndrome (a neurological disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations). Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: -The individual administering the medication must initial the resident's Electronic Medical Administration Record (EMAR) in the appropriate field after giving each medication and before administering the next ones. -As required or indicated for a medication, the individual administering the medication will record in the resident's electronic medical record: -the date and time the medication was administered. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: -When administering an as needed medication: -Document the time of administration. Review of the Minimum Data Set assessment, dated 4/24/25, indicated Resident #8 had received an opioid (a strong prescription pain reliever) medication during the review period. Review of Resident #8's Physician's Orders indicated but was not limited to: - Hydrocodone-Acetaminophen (opioid pain reliever) 7.5-325 milligrams (mg), give 1 tablet by mouth every 6 hours as needed for pain, (start date: 4/4/2025, discontinued: 5/16/2025) - Hydrocodone-Acetaminophen 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (5/16/2025) Review of the EMAR indicated Resident #8 received Hydrocodone-Acetaminophen 41 times from 5/3/25 to 6/18/25. Review of the Narcotic Book (a record book used in healthcare settings to track and document the administration and handling of controlled substances) indicated Resident #8 had received his/her Hydrocodone-Acetaminophen 58 times. Further of Resident #8's EMAR indicated the use of his/her Hydrocodone-Acetaminophen had not been documented 17 out of 58 times (29% of the time). During an interview on 6/18/25 at 12:33 P.M., Nurse #4 said when a resident receives a PRN (as needed) medication, especially if it is an opioid, it should be documented in the EMAR and in the Narcotic Book. The EMAR and Narcotic Book documentation should match. During an interview on 6/18/25 at 3:57 P.M., Nurse #3 said when he administers a PRN medication, he checks the EMAR to see when a PRN medication dose had last been administered to ensure enough time had passed. Nurse #3 said documentation of the time, name, and amount of medication that was administered should match in both the EMAR and Narcotic Book. Nurse #3 said he should have documented in the EMAR but sometimes he would get busy and forget. During an interview on 6/18/25 at 4:25 P.M., the DON said it was her expectation for nurses to follow the standards of practice and the facility's policy and document the use of a PRN medication in the narcotic book and the EMAR. Based on record review and interviews, the facility failed to ensure staff maintained accurate medical records for four Residents (58, #40, #31, and #8), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #58, to ensure the Nurse Practitioner was accurately documenting advance directives as indicated on the Resident's Massachusetts Medical Orders for Life Sustaining Treatment form (MOLST); 2. For Resident #40, to ensure the Resident's active Physician's Orders accurately reflected the Resident's advance directives as indicated on the Resident's MOLST; 3. For Resident #31, to ensure the Resident's active Physician's Orders and Care Plans accurately reflected the Resident's advance directives as indicated on the Resident's MOLST; and 4. For Resident #8, to ensure nursing staff accurately documented the use of an as needed (PRN) medication on the medication administration record (MAR). Findings include: 1. Resident #58 was admitted to the facility in January 2025 with diagnoses including non-traumatic brain dysfunction. Review of the medical record indicated the Resident's Health Care Proxy (HCP) and Nurse Practitioner #1 initiated a new MOLST on 4/3/25. The MOLST reflected the following advance directives: Do not resuscitate (DNR), Do not intubate and ventilate (DNI), do not transfer to hospital (DNH) (unless needed for comfort). Review of Nurse Practitioner #1's 16 progress notes from 4/3/25 to her most recent visit on 6/19/25, indicated -Code Status: Full Code During an interview on 6/23/25 at 10:19 A.M., Nurse Practitioner #1 said her notes and the MOLST form should match. She said all her notes indicated the Resident was a Full Code. She said her notes are incorrect and the MOLST is the most accurate indicator of the advanced directives. She said her notes auto populate from each visit and it must have been an error that the Full Code status was carried over to each visit. She said she expected her documentation in a Resident's medical record to be accurate. During an interview on 6/23/25 at 10:25 A.M., the Director of Nursing (DON) said the information in the medical record should be accurate and complete. She said she expected the nurse practitioner's documentation to be accurate and reflect the Resident's advance directives. She said the nurse practitioner's notes are inaccurate and the Resident's advance directives/code status is DNR/DNI/DNH according to his/her MOLST. 2. Resident #40 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease. Review of the medical record indicated the Resident's HCP and Attending Physician initiated a new MOLST on 6/13/25. The MOLST reflected the following advance directives: Do Not Resuscitate (DNR); Intubate and Ventilate, but Short Term Only; Use Non-invasive Ventilation, but Short Term Only; Transfer to Hospital; No Dialysis; Use Artificial Nutrition, but Short Term Only; and Use Artificial Hydration, but Short Term Only. Review of Resident #40's current Physician's Orders indicated, but was not limited to, the following: -Code Status: (DNR/DNI) Refer to MOLST dated: (5/21/25) Do Not Resuscitate, Do Not Intubate and Ventilate, Use Non-Invasive Ventilation (e.g. CPAP), Transfer to Hospital, No dialysis, Use Artificial nutrition, but short term only, Use artificial Hydration, but short term only [order date: 5/21/25] Review of Resident #40's Physician's Progress Note for a visit on 5/21/25 indicated the Resident's MOLST form was reviewed and the Resident continued as a full code. During an interview on 6/23/25 at 10:25 A.M., the DON said the information in the medical record should be accurate and complete. 3. Resident #31 was admitted to the facility in July 2022 with diagnoses including Alzheimer's disease. Review of the medical record indicated the Resident's HCP and Nurse Practitioner #2 initiated a new MOLST effective 4/18/25. The MOLST reflected the following advance directives: Do Not Resuscitate (DNR); Do Not Intubate and Ventilate (DNI); Do Not Use Non-Invasive Ventilation; Do Not Transfer to Hospital (unless needed for comfort); No Dialysis; No Artificial Nutrition; and No Artificial Hydration. Review of Resident #31's current Physician's Orders indicated, but was not limited to, the following: -Attempt resuscitation, Do no [sic] intubate and ventilate, use non-invasive ventilation, transfer to Hospital, Use dialysis, use artificial nutrition, use artificial hydration [order date: 7/17/24] Review of Resident #31's Care Plans indicated, but was not limited to, the following: -Focus: ADVANCE DIRECTIVES: are as follows: Full Code. Established HCP is invoked. During an interview on 6/23/25 at 10:25 A.M., the DON said the information in the medical record should be accurate and complete.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) policy, and interview, the facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed, implemented and maintained a comprehensive QAPI program with projects that were data driven and had metrics that benchmarked their current status, established goals and defined measurements for improvement for outcomes that were sustainable. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement Program, last dated, January 2025, included but was not limited to the following: - Our QAPI program will be ongoing and comprehensive and includes all employees, all departments, and all services provided. - QAPI will utilize best available evidence (data, benchmarks, published best practice, clinical guidelines) to define and measure goals. - Data to be monitored includes, but is not limited to: quality measures, previous survey deficiencies, complaints or facility monitored incidents, ombudsman concerns, resident/family input - grievance log/resident council, adverse events and med errors. - Evidence and data will be used to benchmark, establish goals and define measures for improvement - The facility Administrator is responsible and accountable for developing, leading, and closely monitoring the QAPI program - QAPI activities are governed and monitored by the QAA committee, which includes the Medical director, Director of Nurses (DON), Administrator, Infection Preventionist (IP) and two additional staff members. - Our organization will conduct Performance Improvement Projects (PIPs) that are designed to take a systematic approach to review and improve care or services in areas that we identify as needing attention; an important aspect of our PIPs is to determine the effectiveness of our performance improvement activities and whether improvement is sustained. - The QAA committee will prioritize topics for PIPs and provide guidance on how to address issues that arise and need corrective action and designate a PIP team - The PIP team will: consider each PIP as a learning process, follow steps for any quality improvement project, determine information needed, determine a timeline for the project, request supplies, staff and equipment as needed, use systematic analysis and systematic actions to identify and implement change. Systematic Analysis and Action: - a systematic approach is used to determine when in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change; to get to the underlying cause of the issue teams work together to identify the root cause and contributing factors using tools such as the five whys. - To prevent future events and promote sustained improvement the organization uses Plan-Do-Study-Act cycles to test actions and recognize and address unintended consequences of planned changes - To ensure planned changes are implemented and effective in making a sustained change the organization uses measure that tie directly to the new action and conducts ongoing periodic measurements and review to ensure the new action has been adopted and performance is consistent. During an interview on 6/23/25 at 1:30 P.M., the Administrator said he is in charge of QAPI and all QAA activities. He said he was involved himself in a project to improve the number of grievances that were communicated accurately using the grievance process. He said he identified that the facility had very few grievances brought forth and it didn't seem the process was being used correctly and he wanted to increase the number to ensure things were not being missed. He said he did not complete a data driven analysis or use a benchmark for the starting point of his project and did not have any measurable data to show an improvement had been made, except that he felt people better understood the grievance process as it is defined within the facility and he felt more grievances had been filed. He said he considered the project recently completed with sustainable results. He said he was aware that a grievance that was recently missed and brought to his attention by the survey team and was a concern. On 6/23/25 at 1:48 P.M., the DON joined the Administrator during the QAPI interview. She said she is currently working on a project to improve the completion of resident incident reports within the facility. She said the regional team identified an issue during a recent audit indicating not all the steps in the incident report and follow up process were being completed. She said the goal is 100% completion but did not know what her starting point was and had no data driven metric to determine how many incident reports were reviewed during the audit or how many were complete versus incomplete. She said she was not measuring improvement periodically and would just consider the project completed once the goal of 100% incident report follow up was met. Throughout the interview both the Administrator and DON said that they are not fully trained or educated on how the process works for determining if a QAPI project is a facility wide QAA project or a PIP and could not indicate what method or cycles of activity the facility and organization used to move throughout the identification, analysis, implementation and measurement checks needed to identify improvement. The Administrator and DON said they had not previously heard of Plan-Do-Study-Act and were unaware of the tools in use by their organization to systematically manage and sustain improvement. The Administrator and DON said they identify a problem, provide education and then monitor the issue, sometimes daily, until they reach their goal of 100% and then consider the project completed. They said they do not seek feedback from their line staff to determine if the education completed for their projects is effective at that level. The DON discussed a project the facility had the previous year for weekly skin checks not being completed as ordered/required. She said the project was initiated off a deficiency from their survey results. She said today she started the project again when a surveyor had brought some concerns regarding skin and the missing skin checks to her attention. She said she was not aware the change had not been sustained. Both the Administrator and the DON said they felt they needed more resources and training on the process of QAA and improvement projects for the program to be fully implemented. During an interview on 6/23/25 at 3:27 P.M., the Director of Operations said the expectation is for the facility leadership to use data-based evidence and metrics to help sustain improvements in identified areas. He said the process would involve a root cause analysis of the situation to identify necessary change and measurable goals and outcomes to determine if the project is effective in creating the desired change or if it would require adjustment for the desired outcomes that could be measured and sustained. He said the facility leadership should be using the organizational process and based on the information provided to the surveyor it seemed that the process for QAA and improvement projects was not in place as it should be. He said that the current process was not comprehensive or inclusive of the organizational requirements.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#168), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's indwelling catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised May 2025, included but was not limited to: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. -The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #168 was admitted to the facility in May 2025 and had diagnoses including uninhibited neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the comprehensive MDS assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of the Admission/readmission Nursing Assessment V3, dated 5/31/25, indicated Resident #168 had a urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 10 cubic centimeter (cc) balloon (5/31/25, discontinued 6/1/25) -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cc balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. Review of comprehensive care plans failed to indicate a care plan had been developed to address the Resident's use of an indwelling urinary catheter. During an interview on 6/23/25 at 2:30 P.M., Consulting Staff #3 said she is covering for the MDS Coordinator while she is on vacation this week. She said the MDS Coordinator is responsible for completion of MDS assessments and care plan development for triggered care areas, but nursing staff can also develop care plans. Consulting Staff #3 reviewed Resident #168's MDS assessment, dated 6/3/25, and the Resident's comprehensive care plans. She said the MDS triggered a care area for urinary catheter and a care plan should have been developed but it was not.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made three errors out of 28 opportunities, resulting in a medication error rate of 10.71%. Those errors impacted two Residents (#11 and #18), out of four residents observed. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: - Medications shall be administered in a safe and timely manner, and as prescribed. - Medications must be administered in accordance with the orders. 1. For Resident #18, Nurse #4 administered: - the incorrect formula of a probiotic (live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the gut). On 6/18/25 at 8:25 A.M., the surveyor observed Nurse #4 prepare and administer medications to Resident #18 including: -Acidophilus (a bacteria-based probiotic) 1 capsule Review of Resident #27's Physician's Orders indicated but was not limited to: -Saccharomyces boulardii (a yeast-based probiotic), give one capsule by mouth two times daily for 14 days, dated 6/5/25 During an interview on 6/18/25 at 12:33 P.M., Nurse #4 said the facility had usually used Acidophilus as a probiotic because it was house stock. Nurse #4 said she had not administered the correct probiotic to Resident #27, and she should have followed the physician's order. 2. For Resident #11, Nurse #2 administered -the incorrect formula of Calcium (supplement used for bone health) -the incorrect formula of Multivitamin with Minerals On 6/18/25 at 8:16 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #11 including: -Oyster Shell Calcium 500 milligrams (mg) plus Vitamin D, 5 micrograms (mcg) -Multivitamin with Minerals (provides a broad range of vitamins and minerals for overall health and well-being) Review of Resident #11's Physician's Orders indicated but was not limited to: -Calcium 500 mg, give one tablet by mouth one time a day, dated 6/30/21 -PreserVision AREDS Tablet (a vitamin and mineral supplement, designed to support eye health), give one tablet by mouth two times a day, dated 4/27/21 During an interview on 6/18/25 at 10:44 A.M., Nurse #2 said she had administered the incorrect formula of Calcium and had administered a Multivitamin with Minerals instead of PreserVision AREDS Tablet to Resident #11. During an interview on 6/18/25 at 4:25 P.M., the Director of Nursing said the expectation was for nurses to administer medications per physician's orders.

Based on observation and interviews, the facility failed to ensure staff provided residents with an environment free from accidents and hazards. Specifically, the facility failed to ensure medications were disposed of on the [NAME] Unit in a secure manner to prevent access to those medications on one of two nursing units. Findings include: Review of the facility's policy titled Destruction of Unused Drugs, last revised [DATE], indicated but was not limited to: -All unused, contaminated, or expired prescription and non-prescription drugs shall be disposed of per facility policy. -Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on [DATE] indicated the [NAME] Unit had 37 out of 39 residents with diagnoses of Alzheimer's disease/Dementia. On [DATE] at 8:25 A.M., the surveyor observed Nurse #4 drop two medications on the floor: - Gabapentin (used to treat seizures and for nerve pain) - Sucralfate (to treat and prevent duodenal ulcer) The surveyor then observed Nurse #4 pick the medications up of the floor and dispose of them into an uncovered trash bin on the side of the medication cart. During an interview on [DATE] at 12:33 P.M., Nurse #4 said she should not have disposed of the medication in the trash on her medication cart. During an interview on [DATE] at 4:25 P.M., the Director of Nursing (DON) said the [NAME] Unit has a large population of residents with Alzheimer's Disease and Dementia. The DON said Nurse #4 should not have thrown the medications into the trash on the side of her cart but disposed of them in the medication disposal area for resident safety.

Based on record review and interview, the facility failed to ensure one Resident (#21), out of a total sample of 17 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically, the facility failed to reposition Resident #21 when he/she was identified to be a very high risk of developing a pressure area resulting in the development of a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue resulting from intense and/or prolonged pressure) to his/her left heel. Findings include: Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to: -Residents with pressure ulcer risk factors are identified, assessed, and provided treatment according to standards of practice. -Residents with actual skin breakdown are identified, assessed and provided treatment according to standards of practice. -Resident's skin integrity status and need for prevention intervention or treatment modalities is identified through review of assessment information. -Identify residents risk level -Care Plan for residents at high risk for skin breakdown -Perform and document skin inspection on admission and weekly Review of the facility's policy titled Pressure Injury Risk Assessment, last revised March 2025, indicated but was not limited to: - It is our policy to perform a pressure injury risk assessment as part of our systemic approach to pressure injury prevention. A risk assessment does not always identify who will develop a pressure injury but will determine which residents are more likely to develop a pressure injury. - Resident determined as at risk for developing pressure injuries will have interventions documented in a plan of care based on specific factors identified in the risk assessment. Resident #21 was admitted to the facility in May 2025 with diagnoses of left femur fracture, diabetes mellitus, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/23/25, indicated Resident #21 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #21 was dependent on staff to roll from side to side and he/she was at risk of developing a pressure ulcer. Review of Resident #21's Admission/readmission Nursing Assessment indicated but was not limited to: -Skin Integrity: -Is Skin intact: No -Classify any wounds: Surgical -Site: Left hip status post left hip hemiarthroplasty (a surgical procedure that replaces only half of a joint) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: Impaired skin integrity as evidenced by/related to: Diabetic, impaired mobility, occasional incontinence of bowel and bladder, anticoagulant/antiplatelet medications, use of splints, braces, immobilizers, status post surgery, left hip and left elbow fracture, diagnosis of diabetes mellitus (initiated 5/5/2025, revised: 6/11/25) -Goal: Skin will remain intact through next review period (initiated 5/5/2025, revised: 5/6/25), Free from additional skin breakdown through next review (initiated 5/5/2025, revised: 6/11/25), Wound/ulcer will show signs of improvement by next review (signs and symptoms of infection, decreased in size) (initiated 5/5/2025, revised: 6/11/25) -Interventions: Pressure redistributing mattress (initiated 5/5/25), Report changes in skin integrity promptly (redness, change in temperature, blisters, etc.) (initiated 5/5/25), Observe for changes in skin integrity related to splints, braces, tubing, positioning tendencies (initiated 5/5/25), Weekly skin checks per protocol (initiated 5/5/25), Barrier cream between incontinent episodes as indicated (initiated 5/6/25) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: I am at risk of skin breakdown related to deconditioning/decreased mobility and incontinence, Surgical wound on left hip, deep tissue injury left heel (initiated 5/12/25, revised 6/13/25) -Goal: The remainder of my skin will be without breakdown through review date (initiated 5/12/25, revised 6/11/25) -Interventions: Identify/document potential causative factors and eliminate/resolve where possible (initiated: 5/12/25), Keep skin clean and dry. Use lotions on dry skin. Provide barrier cream to protect skin. Weekly body audit (initiated: 5/12/25) Review of Resident #21's Care Plans indicated but was not limited to: -Focus: I require assistance with activities of daily living care related to limited mobility, fracture to left upper extremity and left lower extremity (initiated 5/6/2025, revised: 5/8/25) -Goal: I will be assisted with activities of daily living care to be clean, dry, and well-groomed. I will assist as able with activities of daily living care daily (initiated 5/6/2025, revised: 6/11/25) -Interventions: Bed mobility: Dependent (initiated 5/6/2025, revised: 5/8/25) Review of Resident #21's admission Norton Scale for predicting Risk of Pressure Ulcer Assessment (a tool used to assess the risk of a patient developing a pressure injury), dated 5/5/25, indicated but was not limited to: - Physical Condition: Fair - Mental Condition: Alert - Activity: Walks with help - Mobility: Very Limited - Incontinent: Occasional - Deductions: No deductions listed/identified - Score: 15 (Medium Risk) Review of Resident #21's Norton Scale for predicting Risk of Pressure Ulcer Assessment, dated 5/13/25, indicated but was not limited to: - Physical Condition: Poor - Mental Condition: Confused - Activity: Chair Bound - Mobility: Very Limited - Incontinent: Urine and Feces - Deductions: Diagnosis of Diabetes, Hematocrit (the ratio of the volume of red blood cells to the total volume of blood) less than 41%, Hemoglobin (a protein found in red blood cells that is responsible for transporting oxygen throughout the body) less than 14 grams (g)/ deciliter (dL), Albumin level less than 3.3 g/dL, and he/she is on 5 or more medications. -Score: 4 (Very High Risk) During an interview on 6/23/25 at 3:12 P.M., the Director of Nursing (DON) said Resident #21's initial Norton Assessment, dated 5/5/25, was not fully completed by the admitting Nurse. She said Resident #21 was considered high risk for developing a pressure area and no care plan interventions were revised or implemented after the 5/13/25 Norton Assessment which indicated Resident #21 was very high risk for developing a pressure area. Review of Resident #21's Physical Therapy Evaluation, dated 5/6/25, indicated but was not limited to: -Resident #21 required Maximum Assistance (requires substantial help from another person to perform a task, typically 75% or more of the effort) for bed mobility. -Resident #21 had impaired range of motion in his left leg at his/her hip and knee. Review of Resident #21's Physical Therapy Discharge summary, dated [DATE], indicated he/she required Maximum Assistance for bed mobility. Review of Resident #21's Physician Orders indicated but were not limited to: -Skin prep apply to bilateral heels topically two times daily (5/8/25) -Elevated feet on pillows as tolerated while in bed every shift to prevent pressure heels (start 5/6/25 discontinued 5/19/25) -Elevated feet on pillows as tolerated while in bed every shift to prevent pressure heels (5/20/25) -Elevate heels every shift (start 5/8/25, discontinued 5/19/25) -Norton Assessment (used to assess the risk for pressure ulcer in adult patients), (5/5/25) -Hip precautions: Left posterior hip (limiting hip flexion (bending the hip past 90 degrees), avoid crossing the legs or ankles, and preventing internal rotation (turning the left leg inward) every shift (5/7/25) -Weekly skin check every week on Friday, (start 5/5/25, discontinued 6/23/25) Review of Resident #21's positioning documentation from 5/5/25 to 5/18/25 indicated he/she had not been repositioned on 15 out of 36 opportunities (42% of the time) as follows: -36 total opportunities (not including one hospital visit of less than 24 hours) -7 of the 36 opportunities were coded as Not Applicable -3 of the 36 opportunities were left blank -5 out of 36 opportunities were coded as No During an interview on 6/23/25 at 3:12 P.M., the DON said the CNAs should not have left Resident #21's position sheet with blanks areas or marked them as not applicable because that indicated Resident #21 was not repositioned. Review of Resident #21's Nursing Notes indicated but was not limited to: -Date: 5/17/25 at 4:13 P.M., General: Resident #21 has open areas or marks on skin. Worsened areas: No, areas have not worsened. New Areas No new areas. Wound team: notified. -Date: 5/19/25 at 10:52 A.M. During care noted a deep tissue injury dark black 2.5-centimeter (cm) area hard intact cleansed patted dry, skin prep applied followed by abdominal pad and Kling. Nurse Practitioner and Healthcare proxy aware. Review of the Wound Physician's Initial Evaluation, dated 5/22/25, indicated but was not limited to the following: -Unstageable Deep Tissue Injury of the Left Heel -Etiology: Pressure -Size: 4 cm x 3.5 cm, depth is unmeasurable due to the presence of tissue overgrowth, Drainage: None During an interview on 6/20/25 at 1:40 P.M., Certified Nursing Assistant (CNA) #3 said Resident #21 did not have any pressure area and needed to be repositioned every two hours. During an interview on 6/20/25 at 2:05 P.M., CNA #2 said Resident #21 had an open area on their heel and needed to be repositioned every two hours. CNA #2 said she was unaware if Resident #21 was supposed to have his/her heels offloaded. During an interview on 6/23/25 at 8:37 A.M., CNA #4 said she would help with providing care for Resident #21. She said Resident #21 was supposed to be repositioned every two hours and the CNAs should have documented this in Resident #21's positioning sheets. During an interview on 6/23/25 at 8:13 A.M., Nurse #5 said when Resident #21 was admitted his/her skin was intact, and he/she only had a surgical incision. Nurse #5 said Resident #21 had impaired mobility because of a left hip fracture and had interventions in place to offload his/her heels on a pillow, apply skin prep to heels, and to turn and reposition every two hours. Nurse #5 said these were generic interventions for every resident who was considered high risk. During an interview on 6/23/25 at 3:12 P.M., the DON said Resident #21 did not receive their air mattress until 5/19/25 when the pressure area on his/her heel had developed. She said Resident #21 was incredibly high risk for developing a pressure area due to their immobility, comorbidities, and left hip fracture. During a telephonic interview on 6/23/25 at 4:10 P.M., Physician #3 said Resident #21 had a history of a previous healed left heel ulcer and when he/she was admitted to the facility his/her left heel was intact until 5/19/25. During a telephonic interview on 6/25/25 at 3:06 P.M., Physician #2 said when he initially evaluated Resident #21's left heel pressure area it was his evaluation this wound was caused by pressure related to immobility.

Based on record review and interview, the facility failed to ensure nursing staff developed and provided the resident with a summary of the baseline or comprehensive care plan within 48 hours of admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#168), of a total sample of 17 residents. Specifically, the facility failed to ensure a baseline care plan was developed and a summary provided to the Resident for the use of an indwelling urinary catheter. Findings include: Review of the facility's policy titled, Baseline Care Plan, last revised May 2025, indicated but was not limited to: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. -The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social Services. vi. PASARR recommendations, if applicable. -A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. -A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. -A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by the completion of the comprehensive care plan. -The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. Make a copy of the summary for the medical record. Resident #168 was admitted to the facility in May 2025 and had diagnoses including neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the Minimum Data Set (MDS) assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of the Admission/readmission Nursing Assessment V3, dated 5/31/25, indicated Resident #168 had a urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 10 cubic centimeter (cc) balloon (5/31/25, discontinued 6/1/25) -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cc balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. Review of the entire medical record failed to indicate a baseline or comprehensive care plan for the use of an indwelling urinary catheter was developed within 48 hours of Resident #168's admission. During an interview on 6/23/25 at 2:25 P.M., Resident #168 said he/she was admitted to the facility with a urinary catheter. The Resident said he/she was not provided with or asked to sign a summary of a baseline care plan. During an interview on 6/23/25 at 2:30 P.M., Consulting Staff #3 said she is covering for the MDS Coordinator while she is on vacation this week. She said the MDS Coordinator is responsible for completion of MDS assessments and care plan development for triggered care areas, but nursing staff can also develop care plans. Consulting Staff #3 reviewed Resident #168's MDS assessment, dated 6/3/25, and the entire medical record and said the MDS triggered a care area for urinary catheter and a baseline or comprehensive care plan should have been developed within 48 hours but it was not.

Based on interview, observation, and document review, the facility failed to ensure residents/resident representatives had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance for one Resident (#51), out of a total sample of 17 residents. Specifically, the facility failed to ensure staff followed their policy and procedure when Resident #51's Health Care Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) notified staff that the Resident's denture (partial plate) was missing. Findings include: Review of the facility's policy titled Complaint/Grievance Policy and Procedure, dated September 2023, indicated but was not limited to: Policy: -All residents and their responsible representative will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. Procedure: -Staff shall complete a grievance form when residents or responsible representatives make verbal complaints, if not completed by the complainant. -Completed forms should be forwarded to the Grievance Official and notify the Executive Director. -The Grievance Official, or designee in his/her absence, will review the grievance within 24-48 business hours of receipt. -The Grievance Official will oversee the process, track grievances through the conclusion, lead investigations, issue written decisions to residents if requested, and coordinate with State and Federal agencies if necessary. -The Grievance Official will complete the Complaint/Grievance form and submit to the Social Service Department and Administrator (if not the Grievance Official). -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. Resident #51 was admitted to the facility in August 2024 and had diagnoses including dementia. Review of the Minimum Data Set assessment, dated 4/22/25, indicated Resident #51 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, was edentulous and received Hospice services. The assessment indicated Resident #51 had an activated HCP. Review of the medical record indicated a Hospice communication note, dated 6/7/25, indicating the Hospice Aide reported to the staff nurse that Resident #51 was missing his/her denture. Review of a Hospice communication note written by the Hospice Aide, dated 6/16/25, indicated Resident #51's denture was still missing. Review of the facility's grievance book failed to indicate a grievance form was completed for Resident #51's missing denture. Further review of the medical record failed to indicate any documentation regarding the Resident's denture was missing and any efforts to attempt a resolution. During an interview on 6/23/25 at 8:28 A.M., Nurse #5 said she let administration know that the Resident's denture was missing and gave the Resident's HCP a grievance form to complete. She said she is not sure if the HCP ever filled out the papers. The Nurse said she could not recall which staff member in administration she reported the missing denture to. During an interview on 6/23/25 at 9:35 A.M., Unit Manager #1 and the Social Worker reviewed Resident #51's Hospice note dated 6/7/25. The Social Worker said she did not know if a grievance form was completed when the missing denture was reported on 6/7/25. Unit Manager #1 said Resident #51's HCP called her on 6/18/25 and asked that the Resident be seen by the facility's dental provider to get a new denture. She said she faxed a request to the dentist on 6/18/25 and is still waiting to hear back when the Resident can be seen. During a telephonic interview on 6/23/25 at 11:03 A.M., Resident #51's HCP said she discovered that his/her upper denture was missing when she came to visit on 6/7/25. The HCP said she looked everywhere in the Resident's room and was unable to find it. She said staff told her the denture had been missing for a few days, and they were unable to find it either. The HCP said she told Nurse #1 on 6/7/25 that Resident #51's denture was missing and the nurse gave her a grievance form to fill out. The HCP said she did her best to fill out the grievance form and brought it into the facility the following week. She said she did not hear back from the facility and then called the Administrator and Unit Manager #1 on 6/18/25 and was told Resident #51 can be placed on a list to see the dentist the next time he comes in. During an interview on 6/23/25 at 11:50 P.M., the Administrator said he was not aware of Resident #51's missing denture until he received a grievance form completed by his/her HCP on 6/13/25. Review of the grievance form, dated 6/13, indicated that on 6/7/25, the HCP went to get the Resident's denture from its storage cup, and it was empty. She reported the missing denture to the nurse and was told that the denture had been missing for a few days. Staff then came into the Resident's room and searched everywhere but were unable to find the denture. The Administrator said at the time when staff discovered that Resident #51's denture was missing, they should have completed a grievance form and documented the lost dentures so it could be followed through timely, but they did not.

Based on observations and interviews, the facility failed to ensure the privacy and confidentiality of resident information was maintained on one of two nursing units. Specifically, the facility failed to ensure residents' private health information and Activity of Daily Living (ADL) schedule was secure and not accessible to be viewed by anyone walking by the East unit nurses' station. Findings include: Review of the facility's policy titled Promoting/Maintaining Resident Dignity, last revised March 2025, indicated but was not limited to: - Maintain resident privacy - Random observations and/or verifications are conducted by the Director of Nurses or designee to ensure compliance On 6/20/25 at 10:22 A.M., the surveyor observed a multi-page resident information flip chart open on top of the East unit desk, standing up and facing outward towards the hallways. The information that was available for review to people walking by included: four resident's names who were to be gotten up on the 11:00 P.M. to 7:00 A.M. shift and the opposite page included a list for showers and skin checks. On 6/20/25 from 10:22 A.M. to 10:47 A.M., the surveyor observed staff walking past the resident information that was in clear view at the nurses' station 20 separate times. Staff, including the Maintenance director, Maintenance assistant, Director of Nurses, Infection Preventionist, Nurse assigned to the unit, Administrator, Laundry Aide, Regional Food Service Manager, Regional Director of Operations, and Rehab staff all passed the resident specific available information without identifying that it may be a privacy concern. At 10:38 A.M., the Administrator assisted a resident in a wheelchair past the information and at 10:40 A.M., a different resident was observed to self-propel past the information. The information was observed to be available for a total of 37 minutes. During an observation with interview on 6/20/25 at 10:59 A.M., the surveyor observed the Administrator walk past the information again, at which point the surveyor stopped the Administrator and asked him about the information that was on the top of the East nurses' station facing out towards the hallway. He said it is a quick flip chart of information for the Certified Nurse Aides (CNAs) to know which residents need to get up or have showers and includes information on residents who wear splints and have any special needs. He said the flip chart was not supposed to be standing up on the outer perimeter of the nurses' station or facing the hallway and was supposed to be left behind the desk and facing inward towards the nurses' station to keep the residents' information secure. He said the manner in which the information was displayed, facing the hallway and open on the outer perimeter of the top of the nurses' station, was a potential issue for residents' privacy being violated and the flip chart should not be left where any passerby could see it.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#168), out of a total sample of 17 residents, was treated with respect and dignity. Specifically, the facility failed to ensure Resident #168's Foley catheter (tube inserted into the bladder to drain urine) drainage bag was consistently covered with a privacy shield and/or positioned away from the doorway. Findings include: Review of the facility's policy titled Promoting/Maintaining Resident Dignity, last revised March 2025, indicated but was not limited to: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights. -Maintain resident privacy. Resident #168 was admitted to the facility in May 2025 and had diagnoses including neurogenic bladder (a condition where the bladder muscles contract involuntarily, causing frequent and urgent urination). Review of the Minimum Data Set assessment, dated 6/3/25, indicated Resident #168 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had an indwelling urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for diagnosis of neurogenic bladder, catheter size #18 French with 30 cubic centimeter (cc) balloon (6/1/25) -Foley catheter care daily as well as needed (PRN) and every shift (5/31/25) -Empty Foley drainage bag every shift and record output, monitor urine for any abnormalities and notify MD/NP every shift for Foley output (5/31/25) On 6/17/25 at 9:01 A.M., the surveyor observed Resident #168 lying in bed watching television. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. On 6/17/25 at 9:47 A.M., the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. On 6/23/25 at 8:07 A.M., the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. During an observation with interview on 6/23/25 at 8:10 A.M., Unit Manager #1 and the surveyor observed Resident #168 lying in bed asleep. A urinary catheter bag was secured to the bed frame and hanging from the side of the Resident's bed. The drainage bag was visible from the doorway, filled with clear/yellow urine and was not covered by a privacy bag. Unit Manager #1 said the Resident's catheter bag should be covered for privacy.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was alert and oriented and required substantial assistance from staff members when bathing, the Facility failed to ensure that staff treated him/her is a dignified and respectful manner, when related to his/her right to personal privacy when, on 4/03/25 while assisting him/her in the shower, Certified Nurse Aide (CNA) #1 conducted a telephone call using Face Time. Findings include: Review of the Facility Personal Cell Phone Policy, dated as reviewed/revised during January 2025, indicated the Facility prohibited employees from using personal cell phones for any reason on the nursing units. Review of the Facility Resident Rights Policy, dated as reviewed/revised during October 2024, indicated the resident had the right to personal privacy. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during January 2025 and his/her diagnoses included multiple sclerosis. Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/05/25, indicated that Resident #1's cognitive patterns were intact and he/she required substantial assistance from staff members when bathing and showering. During an interview on 4/22/25 at 11:50 A.M., Resident #1 said that on 4/03/25, CNA #1 assisted him/her during a shower. Resident #1 said that during the shower, CNA #1 was on her cell phone. Resident #1 said that the cell phone was on speaker and he/she could hear the conversation between the caller and CNA #1. Resident #1 said that the caller was telling CNA #1 about a relationship break up. Resident #1 said that at some point while he/she was naked and covered in soap, CNA #1 knelt in front of him/her to wash his/her legs and feet. Resident #1 said that when CNA #1 knelt down, the cell phone slid out of his/her scrub top pocket. Resident #1 said that he/she could clearly see the face of the male caller on the cell phone and realized that the call was a Face Time call. Resident #1 was able to describe the physical appearance of the man's face on CNA #1's cell phone. Resident #1 said that he/she made eye contact with the caller and said nice hoodie and the caller replied thanks. Resident #1 said that CNA #1 said oopsie and slid the cell phone back deeper into his/her pocket. Resident #1 said that CNA #1 continued the cell phone conversation throughout his/her shower and only ended the call to dress him/her. Resident #1 said that he/she was shocked, embarrassed and humiliated when he/she realized that CNA #1 was using the cell phone on Face Time and wondered if he/she could be seen by the caller while naked in the shower. During a telephone interview on 4/25/25 at 12:00 P.M., CNA #1 said that she answered a telephone call with her cell phone during Resident #1's shower on 4/03/25. CNA #1 said that she was on the call briefly while she arranged to return the call at another time, that she ended the call and placed the cell phone back into her scrub top pocket. CNA #1 said that at one point after the call, her cell phone fell out of her pocket. CNA #1 said that she thought that Resident #1 mistook a photograph on her telephone screen as a Face Time call. Review of CNA #2 and the Director of Nursing Written Statements, dated 4/04/25, indicated that during a telephone interview of CNA #1 on 4/04/25 conducted by the Director of Nursing during which CNA #2 acted as witness, CNA #1 stated that she was on a Face Time phone call during Resident #1's shower on 4/03/25. Although CNA #1 told the Surveyor that she did not use Face Time when she used the telephone during Resident #1's shower, her statement seems suspect given Resident #1's consistent statements regarding the incident and the corroboratory statements CNA #1 gave during a 4/04/25 telephone interview conducted by the Director of Nursing, as witnessed by CNA #2. During an interview on 4/22/25 at 12:55 P.M., the Director of Nursing said that on 4/04/25, Resident #1 reported that, on 4/03/25, CNA #1 was on a Face Time cell phone call throughout his/her shower. The Director of Nursing said that she called CNA #1 and suspended her. The Director of Nursing said that during the phone call, CNA #1 told her that she had been on a Face Time phone call on 4/03/25 while showering Resident #1. The Director of Nursing said that CNA #1 was terminated as a result of the incident. On 4/22/25 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. The Facility suspended CNA #1 on 4/04/25 and subsequently terminated her. B. Resident #1 was seen by the Facility Social Worker on 407/25, the Psychiatric Service Provider on 4/08/25 and the Nurse Practitioner on 4/09/25 for on-going support related to the incident. C. The Director of Nursing, Administrator and Staff Development Coordinator initiated reinforced training of all staff on the Facility Abuse, Social Media and Cell Phone policies on 4/04/25 and training is on-going. D. On 4/04/25, the Facility initiated random weekly rounds by the Administrator, the Director of Nursing or designee for personal cell phone use by staff members on resident units. E. On 4/07/25, the Facility initiated random interviews of 5 residents weekly to ensure that any potential violations are identified, investigated and reported. F. On 4/04/25, the Facility initiated a Quality Assurance Action Plan for the resident rights violation and the progress was reviewed on 4/16/25 by the QA Committee. G. The Administrator and/or designee are responsible for overall compliance.

Based on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: During an interview on 6/25/24 at 11:13 A.M., the Activity Director (AD) said she used to be the First [NAME] at the facility and picked up hours every other week as an Activity Assistant for a while. She said she was hired as the AD for the facility in July 2023 when the former AD left. She said a few weeks after she started her position as AD, she had to take a leave of absence, and June 2024 is her first full month back to work. Review of the AD's personnel file on 6/25/24 failed to indicate she was qualified therapeutic recreation specialist or an activities professional who had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, or was a qualified occupational therapist or occupational therapy assistant. During an interview with the AD and Regional Activity Director on 6/27/24 at 9:35 A.M., the Regional AD said she was aware the AD is not qualified to direct the activity program at the facility. During an interview on 6/27/24 at 2:15 P.M., the Human Resource Director said the former AD was terminated on 7/19/23, and they have been without a qualified AD since that time.

Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products and maintain safe and clean equipment in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Food: Safe Handling for Foods from Visitors, revised ,d+[DATE], indicated but was not limited to: - Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. - Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and cleaned weekly. Review of the facility's policy, untitled and undated, indicated but was not limited to: - The foodservice department will check for expired products within the inventory. Discard all expired products. If products such as milk will expire before the next visit, discard to prevent negative outcomes. - Place a chart on the refrigerator outlining the expiration period for each item on your floor stock list. Use zip lock bags for condiments and use one label that identifies the date placed in inventory. This will help identify multiple items that expire 3 months or greater. - All open items that are patient items must have a proper label with open and expiration date. Outside items are not exempt from this requirement. In addition to a proper label and date, the patient's name, date of birth, and room number must be placed on the item. Discard items without these requirements. Review of the facility's policy titled Food Storage and Retention Guide, undated, indicated but was not limited to: - Specialty Items- shakes, supplements, thickened beverages: Dry storage and refrigeration at less than or equal to 41 degrees Fahrenheit per manufacturer guidelines. Review of the facility's policy titled Nourishment Room Cleaning, undated, indicated but was not limited to: - Housekeeping is to clean all horizontal and vertical surfaces. - Housekeeping is to dust mop and damp mop all floors. - Dining cleans the inside of the refrigerator. - Dining cleans the inside of drawers where snacks are stored. Review of the facility's cleaning schedule for the East and [NAME] units, undated, indicated but was not limited to: 6:,d+[DATE]:45 Morning Rounds 6:,d+[DATE]:30 Clean on unit common areas (see check sheet) 7:,d+[DATE]:00 Clean off unit common areas (see check sheet) 2:,d+[DATE]:30 Final Rounds Review of the facility's cleaning schedule check sheet for the East and [NAME] units indicated diet kitchen was on the cleaning schedule check sheet. Review of the facility's nourishment kitchenette par level and monitoring checklist, undated, indicated but was not limited to: - Refrigerator cleaned inside and free from any spills. - Everything is labeled and dated clearly. - Microwave is clean inside and out and free from spills and food residue. - Cabinets and drawers are clean and neat and food is rotated. Immediately throw away any food items not labeled including staff meals. On [DATE] at 8:30 A.M., the surveyor observed the following on the [NAME] Unit kitchenette: -Sink faucet and handheld spray nozzle with brown buildup that was easily scraped with fingernail; -Cabinets disorganized with items scattered within; -Drawers disorganized with condiment packages scattered throughout, not bagged and labeled; -Cabinets and hardware with chipping and peeling paint; -Freezer with ice buildup; -One facility container labeled Thick-It with a use by date of [DATE]; -Nine packets of thickened coffee and tea (beverages used as a safety precaution for residents with swallowing difficulties) with use by dates ranging from [DATE] to [DATE]; -One bottle of nutritional supplement in the refrigerator, opened with no label, undated. On [DATE] at 9:00 A.M. and on [DATE] at 8:46 A.M., the surveyor observed the following on the East Unit kitchenette: - microwave interior surface soiled on all sides; - Sink faucet and handheld spray nozzle with brown buildup that was easily scraped with fingernail; - Cabinets disorganized with items scattered and spilled sugar on shelving; - Drawers disorganized with condiment packages scattered throughout, not bagged and labeled; peeling contact paper, and small and large areas of a sticky, dark brown substance; - Cabinets and hardware with chipping and peeling paint; - Refrigerator wire shelving with drips of red liquid hanging from the wires; red drips on the lid of a Resident's yogurt; - One container of a resident's prune juice, opened, undated. Manufacturer's label read consume within ,d+[DATE] days; - Ice cream with no label, undated; - Two packages of cake mix in the freezer with no label, undated. During an interview with observation on [DATE] at 12:30 P.M., the Food Service Director (FSD) said the kitchen staff stocks the Unit kitchenettes, monitors item dating and labeling, monitors for expiration dates, and cleans the refrigerator and freezer. The FSD also said kitchen staff are responsible for cleaning drawers. The FSD and the surveyor observed the East Unit kitchenette together. The FSD said the refrigerator, freezer, drawers, and cabinets needed cleaning. The FSD said the sink faucets and the hand nozzles should be cleaned of buildup. The FSD said resident food items stored in the Unit kitchenettes should be labeled and dated and any food or drink that is expired or past the written use by date is discarded. The FSD said she was unaware of the prune juice's consumption range of seven to ten days after opening, and she was unaware of the expired thickened beverage packets in the [NAME] Unit kitchenette. The FSD said these items should have been discarded.

Based on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Infection Preventionist failed to attend the last two quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), dated as revised 3/4/24, indicated but was not limited to: - The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. - The QAA Committee shall be interdisciplinary and shall consist at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and the Infection Preventionist. Review of the QAPI Attendance Sheets, dated 1/19/24, 2/26/24, 3/15/24, and 4/26/24, failed to indicate the Infection Preventionist was in attendance and the designated signature space was blank. Further review of the QAPI Attendance Sheets indicated the Quarterly Meetings were held on 1/19/24 and 4/26/24. During an Interview on 7/1/24 at 12:10 P.M., the Chief Nursing Officer (CNO) reviewed the QAPI Attendance Sheets, dated 1/19/24, 2/26/24, 3/15/24, and 4/26/24 and said the facility IP had not signed in. The CNO said the expectation was for the facility IP to be present at the QAPI Meetings. 48695

Based on interviews and record review, the Facility failed to provide adequate supervision and effective interventions to prevent accidents/elopements per facility policy for 2 Residents (#6 and #7) and failed to fully investigate the cause of 1 Resident's (#3) fall with fracture, from a total sample of 16 Residents. Findings included: The Facility policy for Elopement: overview dated as revised in 07/2009 was located in a yellow binder on each unit and was reviewed with the Administrator on 04/20/17 at 4:20 P.M. The policy indicated the missing resident/patient action plan should be initiated if staff were unable to locate a resident/patient. The Facility policy for Elopement: facility practices indicated the following: -assess for internal environmental risk factors, including exit doors -maintain door alarms and wander control systems in proper working order -identify external environment risk factors including busy streets/highways -review and correct deficiencies in practices related to identification of residents, response alarms and testing alarms -maintain a list of residents at risk for elopement -monitor whereabouts of the at risk resident during rounds 1. For Resident #6 the Facility failed to appropriately assess the risk for elopement, failed to follow their policies and procedures for a missing resident, failed to thoroughly investigate the elopement, and failed to thoroughly assess risk factors including but not limited to exit doors. Resident #6 was found on 03/03/17 around 3:00 A.M., one mile from the Facility. The Facility was located on a highway with a speed limit of 45 MPH (miles per hour.) The Resident was not seen by Facility staff for an undetermined amount of time and the outside temperature was 28 degrees Fahrenheit. Local Police and Emergency Medical Sevices (EMS) were called by the Resident's daughter to help her father/mother. Resident #6 was admitted to the Facility in 10/2016 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #6 scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS) indicating the Resident was cognitively intact. The Resident was at a level of supervision for ambulation, with no physical assist from staff and no assistive devices. Review of the physician progress notes [REDACTED]. The Administrator and DON were interviewed on 04/21/17 at 3:40 P.M. The Administrator said she interviewed Nurse #1 who admitted she threw away the original elopement assessment for Resident #6 on 04/11/17, as she did not feel it was accurate and recreated an assessment. The original Elopement risk data collection and assessment, completed as part of the admission assessments, for Resident #6 was unable to be located by Facility staff. The Elopement risk data collection and assessment dated [DATE] for Resident #6 was reviewed. The form was signed as completed by the Administrator. The form indicated a pre-data collection of reviewing any previous elopement risk data collection and assessments was not completed. The Risk Factors checked off for Resident #6 were impaired cognition and independently mobile. The Administrator was interviewed on 04/21/17 at 3:40 P.M. and said she assessed Resident #6 to not be at risk for elopement on 01/28/17 because he/she was adjusting well to the Facility. She said she was unsure why she had not checked off on the assessment other risk factors pertaining to the Resident including alcohol or drug abuse, anxiousness, impaired vision, expressed desire to leave or psychiatric history. A review of an investigation and progress notes indicated Resident #6 was observed to not be in his/her room on 03/03/17 at 2:00 A.M. by a Certified Nursing Assistant (CNA). The CNA notified the Nurse (Nurse #2) and the other CNA. CNA #2 then went to the West Unit and notified the two CNAs and one Nurse. The staff searched Resident rooms and bathrooms. At 2:30 A.M. the daughter of Resident #6 called the Facility stating the Resident called her and she believed he/she was no longer in the Facility. The staff continued to search the Facility and outside premises. The Nurse notified the police, the DON and the Administrator at 2:55 A.M., which was 55 minutes after the Resident was noticed to not be in his/her room. Review of the investigation provided by the Administrator included a statement from Nurse #2, CNA #1, CNA #2 and the Nurse and 2 CNAs from the West Unit. Conflicting statements were obtained from CNA #1 and CNA #2, both stating they had noticed the Resident was not in his/her room at 2:00 A.M. There was one staff statement from the Nurse who had worked 3:00 P.M. to 11:00 P.M. on 03/02/17, stating she last saw the Resident at 9:45 P.M. There were no other statements from the staff who worked 3:00 P.M. to 11:00 P.M. on 03/02/17. There was not an incident report included with the investigation as indicated in the Elopement policy of the Facility. There was not a missing resident action plan included with the investigation as indicated in the Elopement policy of the Facility. There were no police reports or EMT (Emergency Medical Technician) reports included with the investigation. There was no time line of events included with the investigation. A progress note from 03/03/17 indicated the social worker completed the BIMS with Resident #6 who had a score of 12/15, indicating a moderate cognitive impairment. During an interview with the Administrator on 04/21/17 at 1:20 P.M. she said the conclusion to the investigation was that a pharmacy delivery driver let the Resident out of the building at 1:18 A.M. The Administrator said she interviewed Resident #6 on 03/03/17 who said he/she was upset about being told he/she could not have a beer and stated a white guy let him out of the building. The Administrator said through investigation it was determined the last person to see the Resident was a nurse at 9:45 P.M. on 03/02/17. Review of the physician's progress note dated 03/13/17 did not mention the elopement. Review of the psychiatric progress note dated 04/18/17 indicated a chief complaint of anxiety and that Resident #6 was adjusting well to the secure unit, without mention of the elopement. There were no other physical or psychosocial assessments completed by a physician following the elopement to determine the impact of the elopement on the Resident. Review of the medial record indicated there was no care plan in place for elopement prevention. During an interview with the Administrator and DON on 04/21/17 at 3:40 P.M. they stated there was no care plan initiated as they did not feel Resident #6 was at risk, despite the elopement assessment completed on 03/03/17 indicating the Resident was at risk. The Administrator said the plan for Resident #6 was to provide one beer at lunch and one at dinner. Review of the medical record on 04/21/17 indicated there was not an order for [REDACTED].#6 since 03/07/17. On 04/26/17 at 12:45 P.M. the DON provided the Surveyor with a police report regarding Resident #6 from 03/03/17. The police report indicated they were called at 3:02 A.M. on 03/03/17 by Nurse #2 regarding a missing Resident (1 hour and 2 minutes after the Resident was not found in his/her room.) Upon arrival, the Police Officer was told by staff that Resident #6 had probably left on the previous shift and that the staff were aware that he/she had been missing for an hour. The Police report indicated two other officers located the Resident and his/her daughter on the side of the road, 1 mile from the Facility. Resident #6 was found by a motorist laying on the side of the road on Route 6. The Resident was wearing a bomber style jacket, light pants and sneakers. An ambulance was dispatched as the Resident was outside for an undisclosed amount of time, the temperature outside was 28 degrees Fahrenheit, with a wind chill temperature of 20 degrees Fahrenheit. The DON was interviewed on 04/26/17 at 12:45 P.M. The DON said she had not previously seen this Police report and was unaware that staff said the Resident left the shift prior, that the Resident was lying on the ground, and had not obtained or reviewed the EMT report. 2. For Resident #7 the Facility staff failed to appropriately assess the risk for elopement, failed to follow their policies and procedures following an elopement, failed to thoroughly investigate the elopement, and failed to thoroughly assess risk factors including but not limited to exit doors. Resident #7 was admitted to the Facility in 07/2015 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 scored a 06 out of 15 on the Brief Interview of Mental Status (BIMS) indicating the Resident was severely cognitively impaired. The Resident was independent for ambulation, with no physical assist from staff and no assistive devices. A review of an Elopement risk data collection and assessment dated [DATE], signed as completed by the Administrator was conducted, then reviewed on 02/26/17 and 04/02/17. The Risk Factors checked off for Resident #7 were elopement history, expresses desire to leave, impaired cognition, exit seeking behavior, and restless/irritable. The Administrator was interviewed on 04/20/17 at 4:00 P.M. and said she assessed Resident #7 to not be at risk for elopement when the assessment was originally completed on 11/26/16 and the risk factors were added (but not dated) upon re-assessment on 04/02/17. The Administrator said the Resident had not expressed a desire to leave the Facility prior to 04/02/17. A review of the nursing progress notes for Resident #7 indicated on 11/25/16 Resident #7 stated I just want to go home and to call his/her son. On 04/21/17 at 9:30 A.M. the Administrator said she was unaware of this statement when she assessed Resident #7 on 11/26/16 and when the DON assessed the Resident on 02/26/17. A review of the care plans for Resident #7 indicated a care plan for Elopement risk was initiated on 11/26/16 noting that the Resident was actively exit seeking with interventions of elopement risk identification sheet in the Elopement book and monitor Resident for tailgating (closely following someone out the door) when visitors are in the facility. The care plan for Behaviors indicated the Resident could become agitated when he/she could not recall the reason for living in the Facility related to a [DIAGNOSES REDACTED]. A review of an investigation and progress notes indicated Resident #7 was observed to be on Route 6 at the edge of the property on 04/02/17 at 1:45 P.M. The Resident was seen by Activity Aide #1 as she was coming to work. Activity Aide #1 stopped her car at the edge of the property and walked Resident #7 back to the Facility. Activity Aide #1 informed the Nurse on duty. When the Nurse on duty did not initiate calls to the Administrator, the Activity Aide called the Administrator at 2:15 P.M. Review of the investigation provided by the Administrator included a statement from the Nurse and three CNAs who were working on the East unit. There were no other statements from the staff who worked 7:00 A.M. to 3:00 P.M. on 04/02/17. There was no time line of events included with the investigation to indicate how long the Resident had been out of the Facility. The conclusion drawn by the Administrator indicated the Resident exited the building after a visitor, there were no witness statements from visitors included in the investigation. The Facility layout was observed with the Administrator on 04/21/17 at 9:15 A.M. There was a set of double doors off of the main lobby (between the East and West Units) that lead to a hallway. At the end of the hallway was an alarmed door. The Administrator said that upon assessment and review with maintenance it was determined that the alarmed doors all had a tailgate function which allowed the door to remain unalarmed for 15 seconds after the code was entered. The Administrator said this function was turned off following the elopement of Resident #7. A review of the psychiatric visit from 04/05/17 indicated Resident #7 eloped in 02/2017. The psychiatric Nurse Practitioner was interviewed on 04/21/17 at 10:00 A.M. She said she was informed on 04/05/17 that the Resident had also attempted to leave the Facility in 02/2017 and was found trying to exit the double doors off of the main lobby. The NP said she had spoken with a nurse on 04/05/17 who provided this information but was unable to recall who this was. The Administrator and DON were interviewed on 04/21/17 at 4:00 P.M. and said they were unaware of an attempt by Resident #7 to leave the Facility in 02/2017. The Director of Nursing and the Administrator were interviewed on 04/20/17 at 4:00 P.M. and said the Facility had a policy to call a code purple if there was a missing Resident. An interview was conducted with UM #1 on 04/25/17 at 3:30 P.M. UM #1 said she was unaware of any code that the Facility used to notify staff of a missing resident. An interview was conducted with CNA #1 on 04/25/17 at 4:00 P.M. CNA #1 said she had never heard of or been educated on a code purple. An interview was conducted with CNA #3 on 04/25/17 at 4:05 P.M. CNA #3 said he had never heard of a code purple and would be unsure what to do if one was announced. During an interview with the Administrator on 04/25/17 at 3:45 P.M. the Administrator confirmed there was not a written policy regarding a code purple. The Administrator said the missing resident action plan was not completed for either elopement. The Administrator confirmed she was unaware of the tailgate function on the alarmed doors until after the second elopement. 3. For Resident #3 the Facility failed to investigate a fall which resulted in a fracture, per their facility policy. Resident #3 was admitted to the Facility in 5/2015 with [DIAGNOSES REDACTED]. The change in status MDS assessment, dated 3/7/17, indicated that Resident #3 was severely impaired in daily decision making, he/she required assistance with transfers, ambulation and bathing. Review of the nurse's note, dated 3/21/16, indicated that at 12:40 P.M., Resident #3's alarm sounded, he/she was in the doorway of a room and when a CNA attempted to assist him/her and Resident #3 fell and he/she complained of a limp in the left leg. The nurse's note indicated that the Physician ordered an X-ray which indicated that Resident #3 sustained an acute right pubic fracture. The Surveyor requested the internal investigation for the fall on 3/21/16 and the DON said she was unable to locate any internal investigation for Resident #3. Review of the incident report, dated 12/31/16, indicated that Resident #3 was found on the floor next to the bed, with alarm sounding. The incident report indicated that Resident #3 may have been going to the bathroom. The DON was unable to produce any evidence of a complete and thorough investigation with witness statements and conclusion according to the Facility policy.

Based on records reviewed and interviews for 2 of 3 sampled residents (Resident #1 and #2), the Facility failed to ensure that a thorough investigation was conducted into surrounding events involving two unwitnessed falls resulting in Resident #1 sustaining a fractured right hip and Resident #2 sustaining a laceration with a nasal fracture, both injuries of unknown origin. Findings include: The Facility's Policy titled Incident Reports indicated the supervisor/unit manager will review reports immediately with employees and obtain statements. The policy further indicates to make copies of past 24 hour staffing to get statements as appropriate ( injuries of unknown origin) and the unit manager must complete an investigation and return the incident report to the ADON/DON. The incident report will be forwarded to the Administrator and DON for final review and signature after the completion of the investigation. The Facility's Policy titled How to Conduct an Investigation indicated the facility has processes to enable it to come to a resolution after thoroughly investigating all accidents and incidents by interviewing all potential witnesses, determining what occurred, documenting on the accident/incident follow-up and documenting the results/analysis on the accident/incident final disposition report. Resident #1's Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired and required supervision with ambulation and extensive assist with transfers. An Event/Incident Report, dated 11/24/16 at 1:15 P.M., indicated CNA#2 reported that another resident, name unknown, yelled out that Resident #1 was falling and when CNA#2 turned, Resident #1 was lying on the floor. A witness statement, dated 11/24/16, indicated CNA #2 heard another resident, name unknown, yelling for help and when CNA #2 turned around, she saw Resident #1 on the floor in the day room A Nurse Progress note, dated 11/24/16, indicated Resident #1 sustained a fall witnessed by an unidentified resident. Resident #1's fall was unwitnessed by facility staff. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed CNA #2 at 2:27 P.M. on 2/13/17. CNA #2 said she was in the day room assisting a resident when she heard another unidentified resident yell out Resident #1 just fell . CNA #2 said she turned around and saw Resident #1 on the floor. CNA #2 said she did not witness Resident #1 fall and informed Nurse #1 that Resident #1 was on the floor. The Surveyor interviewed Nurse #1 at 3:37 P.M. on 2/13/17. Nurse #1 said she did not witness Resident #1 fall, recalls Resident #1 complained of pain and informed Nurse #4 of Resident #1's pain. Nurse #4 did not respond to the Surveyor's requests for interview made by telephone or by letter sent to the address of record at the Facility as of the date of this Statement of Deficiency. The Surveyor interviewed the Director of Nurses (DON) at 5:10 P.M. on 2/13/17 and throughout the day on 2/14/17 and 2/21/17. The DON said Resident #1's incident report is an investigation and the Facility does not do any further investigation or obtain further witness statements after every incident or fall as long as an intervention is put into place. This is inconsistent with Facility Policy. Resident #2's Minimum Data Set (MDS), dated [DATE] indicated, Resident #2 was severely cognitively impaired and required supervision with ambulation and transfers. An Event/Incident Report, dated 1/23/17 at 2:30 A.M. indicated Nurse #2 was called into Resident #2's room by staff member. Resident #2 was noted to have a bloody nose, laceration, bruise to bridge of his/her nose, complained of pain and stated he/she fell . A Nurse Progress note, dated 1/23/17, indicated Resident #2 was walking out of his/her room with a bloody nose, laceration, bruise to bridge of his/her nose, complaining pain and stated he/she fell . This was inconsistent with Event/Incident Report. Resident #2 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed Nurse #2 at 9:39 A.M. on 2/21/17. Nurse #2 said on 1/23/17 on the 11 P.M. -7 A.M. shift, CNA's were doing rounds and called her into Resident #2's room. Nurse #2 said she saw Resident #2 sitting on the floor with a bloody nose and Resident #2 stated to Nurse #2 he/she fell . Nurse #2 said the unit manager or DON is responsible for doing an investigation after a fall. The Surveyor interviewed the Director of Nurses (DON) at 5:10 P.M. on 2/13/17 and throughout the day on 2/14/17 and 2/21/17. The DON said the facility does not have a policy on injuries of unknown origin and does not do an investigation or obtain witness statements after every incident or fall. The DON said facility documentation is sketchy and lacking and an investigation and witness statements should have been completed for Resident #2's injury of unknown origin. The DON said she is responsible for completing the investigation. This is inconsistent with Facility Policy. The Facility was unable to provide supporting documentation that a thorough investigation was completed in accordance with Facility policy, into the events surrounding how Resident #1 fell sustaining a fractured right hip and Resident #2's injury of unknown origin who was found on floor with laceration on nose resulting in a nasal fracture. Resident #1 and Resident #2 were transferred to the hospital.

Based on records reviewed and interviews, for 2 out of 3 sampled residents, (Resident #1 and Resident #2), who both had the [DIAGNOSES REDACTED].#1 who fell and sustained a right hip fracture and Resident #2 sustained a nasal fracture and laceration. Findings include: The Facility's policy titled Falls Management indicated the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Resident #1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired and required supervision with ambulation and extensive assist with transfers. An Activity of Daily Living (ADL) flow sheet, dated November 2016, utilized by the Certified Nurse Assistant (CNA), indicated Resident #1 required continual supervision with transfers and ambulation. An Activities of Daily Living (ADL) Care plan, dated 11/16, did not indicate Resident #1's mobility status. An Individualized Care Plan for Fall/Fall Risk, dated 11/16, indicated Resident #1 used a rolling walker but did not indicate his/her mobility status. An Event/Incident Report, dated 11/24/16 at 1:15 P.M., indicated CNA#2 reported that an unidentified resident yelled out that Resident #1 was falling and when CNA#2 turned, Resident #1 had already fallen down. Resident #1 complained of pain to his/her left thigh and was unable to move his/her left thigh. A witness statement, dated 11/24/16, indicated CNA #2 heard an unidentified resident yelling for help and CNA #2 saw Resident #1 on the floor in the day room. A Nurse Progress note, dated 11/24/16, indicated Resident #1 sustained a fall witnessed by an unidentified resident. Resident #1's incident was unwitnessed by facility staff. The Surveyor interviewed CNA #2 at 2:27 P.M. on 2/13/17. CNA #2 said she was in the day room assisting a resident when she heard another unidentified resident yell out Resident #1 just fell . CNA #2 said she turned around and saw Resident #1 on the floor. CNA #2 said she did not witness Resident #1 fall and informed Nurse #1 that Resident #1 was on the floor. CNA #2 said Resident #1 required supervision and a walker for ambulation but would often ambulate to his/her room, toilet self, transfer self into bed without staff supervision after lunch. CNA #2 said it was difficult for the staff to supervise Resident #1 at all times because there are so many resident's who need to be supervised at the same time. This was inconsistent with Resident #1's needs. The Surveyor interviewed Nurse #1 at 3:37 P.M. on 2/13/17. Nurse #1 said Resident #1 required supervision and a walker for ambulation however, would often ambulate without his/her walker on the unit and transfer self into bed without staff supervision. There was no care plan developed for mobility. The Facility was unable to provide supporting documentation that a Fall Risk Assessment was performed for Resident #1. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] indicated, Resident #2 was severely cognitively impaired and required supervision with ambulation and transfers. An Activities of Daily Living (ADL)/ Self Care Deficit Care plan, dated 12/16 indicated Resident #2 required supervision with ambulation, assist as needed. A Fall Risk Assessment, dated 12/19/16, indicated Resident #2 was assessed at high risk for falls. An Event/Incident Report, dated 1/23/17 at 2:30 A.M. indicated, staff member called Nurse#2 into Resident #2's room. Resident #2 was noted to have a bloody nose, laceration, bruising to bridge of his/her nose, stated he/she fell and complained of pain. A Nurse Progress note, dated 1/23/17, indicated Resident #2 was walking out of his/her room with a bloody nose, laceration, bruise to bridge of his/her nose, complained of pain and stated he/she fell . Resident #2 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Hospital Diagnostic Imaging Head CT (computed tomography) Scan Report, dated 1/23/17, indicated Resident #2 had a minimally displaced nasal bone and septal fracture. The Surveyor interviewed Nurse #2 at 9:39 A.M. on 2/21/17. Nurse #2 said on 1/23/17 on the 11 P.M. -7 A.M. shift, CNA's were doing rounds, called her into Resident #2's room and she saw Resident #2 sitting on the floor with a bloody nose and stated he/she fell . Nurse #2 said Resident #2 was independent, walked freely in his/her room, did not have any alarms or require supervision. This was inconsistent with his/her care plan. The Surveyor interviewed the Director of Nurses (DON) at 5:10 P.M. on 2/13/17 and throughout the day on 2/14/17 and 2/21/17. The DON said the facility does not have a policy on supervision. The DON said if supervision means you have to keep an eye on the resident at all times that means the resident should be a 1:1 and the facility was unable to keep an eye on the residents at all times or provide supervision in that sense and she needed to get further clarification about what supervision meant or words to that effect . The Facility was unable to provide any documentation on the Activity of Daily Living (ADL) flow sheet to indicate staff provided supervision for Resident #2, which resulted in Resident #2's nasal fracture and failed to provide adequate supervision to prevent Resident #1's fracture left hip.

Based on interview and record review of three of ten sampled residents (Residents #1, #2 and #3), the Facility failed to investigate allegations of potential abuse of these residents by Certified Nurse Aide (CNA) #1, which occurred over approximately a five month period prior to May 2015. Although CNA #2, CNA #3, CNA #4, and Nurse #1 said they either observed or heard CNA #1 interact with Resident #1, Resident #2, and Resident #2 in a manner that was of concern to them, they all failed to ensure the incidents were immediately reported to the Administrator. The incidents include the following: - CNA #4 said she observed CNA #1 belittling Resident #2 and Resident #3 for four or five months (since January or February 2015); CNA #4 documented in a written statement she saw and heard CNA #1 yell at Resident #2 and Resident #3 for soiling their incontinence briefs and CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported her concerns about CNA #1 to Nurse #2 about four or five months ago (January or February 2015). - CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and said words to the effect, stop[***]ing all over the place. - In his written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents (not identified) around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and referred to them as assholes. - CNA #2 said that on 5/20/15, CNA #1 belittled Resident #1, called him/her a [***] ing animal and disgusting, and told Resident #1 to shut up. - CNA #2 said CNA #1 yelled at Resident #1 and Resident #2. Findings include: Resident #1's Care Plan for Cognitive Loss, dated April 2015, indicated Resident #1 had impaired cognition related to dementia, [MEDICAL CONDITION] and weakness. Interventions included: promote dignity; converse with Resident #1; and ensure privacy while providing care. Resident #1's Care Plan for Activities of Daily Living (ADLs), dated April 2015, indicated Resident #1 had a self care deficit. Interventions included encourage him/her to accept the assistance necessary to ensure tasks were successfully completed. Resident #2's Care Plan for Cognitive Loss, dated 6/27/14, indicated Resident #2 had impaired cognition due to [DIAGNOSES REDACTED]. Resident #2's Care Plan for Activities of Daily Living, dated 6/27/14, indicated Resident #2 had a self care deficit and he/she required assistance with bed mobility, dressing, eating and toilet use. Resident #3's Care Plan for Cognitive Loss, dated 12/8/14, indicated Resident #3 had impaired cognitive skills. Resident #3's Care Plan for ADLs, dated 12/8/14, indicated he/she had a self care deficit. 1. The Surveyor interviewed CNA #4 at 3:20 P.M. on 6/11/15. CNA #4 said she has observed CNA #1 belittling Resident #2 and Resident #3 for months. In a written statement, dated 5/21/15, CNA #4 indicated the following. CNA #4 witnessed verbal abuse by CNA #1 toward Resident #2 and Resident #3. CNA #4 indicated CNA #1 yelled at them for soiling their briefs. CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported this to Nurse #2 about four or five months ago (January or February 2015). The Surveyor interviewed Nurse #2 at 9:20 A.M. on 6/15/15. Nurse #2 told the Surveyor she could not recall receiving a report from CNA #4, but Nurse #3 remembered that CNA #4 reported her concerns. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 6/15/15. Nurse #3 said she recalled CNA #4 speaking to Nurse #2 about CNA #1. Nurse #3 said she heard Nurse #2 call the Director of Nurses to report CNA #4's concerns. Nurse #3 said she did not recall when this took place, but thought it was sometime in the winter. The Surveyor interviewed the Director of Nurses at 9:30 A.M. and throughout the day on 6/11/15. The Director of Nurses denied receiving a report from Nurse #2 about CNA #1. This was not consistent with the Accounts of CNA #4 or Nurse #3. 2. The Surveyor interviewed CNA #3 at 12:38 P.M. on 6/11/15. CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and said words to the effect, stop[***]ing all over the place. CNA #3 said he thought CNA #1 was too aggressive with Resident #3's care. In his written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and that they were assholes. CNA #3 said he was a new employee and did not report his observations to anyone. 3. The Surveyor interviewed CNA #2 at 11:00 A.M. on 6/11/14. CNA #2 said on 5/20/15, she heard CNA #1 use profanities when speaking to Resident #1. CNA #2 said she heard CNA #1 call Resident #1 a [***] ing animal. CNA #2 said she heard CNA #1 tell Resident #1 he/she was disgusting and to shut up. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 6/15/15. Nurse #1 said she was administering medication outside Resident #1's room, when she heard CNA #1 tell Resident #1 to keep his/her mouth shut. Nurse #1 said she spoke to CNA #1 about the comment she made to Resident #1. There was no indication Nurse #1 reported what she heard. CNA #2 said that on 5/20/15, she also observed CNA #1 providing incontinence care to Resident #2, CNA #2 said CNA #1 was angry and shoved Resident #2 to move him/her in the bed. CNA #2 said she saw what she considered to be abusive treatment of [REDACTED].

Based on interview and record review of three of ten sampled residents (Residents #1, #2 and #3), the Facility failed to ensure that allegations of abuse occurring between January or February 2015 and 5/20/15 were identified, immediately reported to the designated abuse coordinator and investigated, and that residents were protected from further abuse, in compliance with the Facility's Policy and Procedure on Abuse, Neglect, Exploitation and Mistreatment of [REDACTED]. - CNA #4 said she observed CNA #1 belittling Resident #2 and Resident #3 for four or five months (since January or February 2015); CNA #4 documented in a written statement she saw and heard CNA #1 yell at Resident #2 and Resident #3 for soiling their incontinence briefs and CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported her concerns about CNA #1 to Nurse #2 about four or five months ago (January or February 2015). - CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and said words to the effect, stop[***]ing all over the place. - In his written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents (not identified) around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and referred to them as assholes. - CNA #2 said that on 5/20/15, CNA #1 belittled Resident #1, called him/her a [***] ing animal and disgusting, and told Resident #1 to shut up. - CNA #2 said CNA #1 yelled at Resident #1 and Resident #2. Findings include: Resident #1's Care Plan for Cognitive Loss, dated April 2015, indicated Resident #1 had impaired cognition related to dementia, [MEDICAL CONDITION] and weakness. Interventions included: promote dignity; converse with Resident #1; and ensure privacy while providing care. Resident #1's Care Plan for Activities of Daily Living (ADLs), dated April 2015, indicated Resident #1 had a self care deficit. Interventions included encourage him/her to accept the assistance necessary to ensure tasks were successfully completed. Resident #2's Care Plan for Cognitive Loss, dated 6/27/14, indicated Resident #2 had impaired cognition due to [DIAGNOSES REDACTED]. Resident #2's Care Plan for Activities of Daily Living, dated 6/27/14, indicated Resident #2 had a self care deficit and he/she required assistance with bed mobility, dressing, eating and toilet use. Resident #3's Care Plan for Cognitive Loss, dated 12/8/14, indicated Resident #3 had impaired cognitive skills. Resident #3's Care Plan for ADLs, dated 12/8/14, indicated he/she had a self care deficit. 1. The Surveyor interviewed CNA #4 at 3:20 P.M. on 6/11/15. CNA #4 said she has observed CNA #1 belittling Resident #2 and Resident #3 for months. In a written statement, dated 5/21/15, CNA #4 indicated the following. CNA #4 saw CNA #1 verbally abuse Resident #2 and Resident #3. CNA #4 indicated CNA #1 yelled at them for soiling their briefs. CNA #4 said CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported this to Nurse #2 about four or five months ago (January or February 2015). The Surveyor interviewed Nurse #2 at 9:20 A.M. on 6/15/15. Nurse #2 could not recall receiving a report from CNA #4, but she said Nurse #3 remembered that CNA #4 reported her concerns. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 6/15/15. Nurse #3 said she recalled CNA #4 speaking to Nurse #2 about CNA #1. Nurse #3 said she heard Nurse #2 call the Director of Nurses to report CNA #4's concerns. Nurse #3 said she did not recall when this took place, but thought it was sometime in the winter. The Surveyor interviewed the Director of Nurses at 9:30 A.M. and throughout the day on 6/11/15. The Director of Nurses denied receiving a report from Nurse #2 about CNA #1. 2. The Surveyor interviewed CNA #3 at 12:38 P.M. on 6/11/15. CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and told him/her to stop[***]ing all over the place. In his written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and that they were assholes. CNA #3 said he was a new employee and did not report his observations to anyone. 3. The Surveyor interviewed CNA #2 at 11:00 A.M. on 6/11/14. CNA #2 said on 5/20/15, she heard CNA #1 use profanities when speaking to Resident #1. CNA #2 said she heard CNA #1 call Resident #1 a [***] ing animal. CNA #1 said she heard CNA #1 tell Resident #1 he/she was disgusting and to shut up. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 6/15/15. Nurse #1 said she was administering medication outside Resident #1's room, when she heard CNA #1 tell Resident #1 to keep his/her mouth shut. Nurse #1 said she spoke to CNA #1 about the comment she made to Resident #1. CNA #2 said that on 5/20/15, she also observed CNA #1 providing incontinence care to Resident #2, CNA #2 said CNA #1 was angry and shoved Resident #2 to move him/her in the bed.

Based on interview and record review of three of ten sampled residents (Residents #1, #2 and #3), the Facility failed to ensure these residents were free from abuse between January or February 2015 and 5/21/15. Incidents included: - CNA #4 said she observed CNA #1 belittling Resident #2 and Resident #3 for four or five months (since January or February 2015); CNA #4 documented in a written statement she saw and heard CNA #1 yell at Resident #2 and Resident #3 for soiling their incontinence briefs and CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported her concerns about CNA #1 to Nurse #2 about four or five months ago (January or February 2015). - CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and said words to the effect, stop[***]ing all over the place. - In his written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents (not identified) around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and referred to them as assholes. - CNA #2 said that on 5/20/15, CNA #1 belittled Resident #1, called him/her a [***] ing animal and disgusting, and told Resident #1 to shut up. - CNA #2 said CNA #1 yelled at Resident #1 and Resident #2. Findings include: Resident #1's Care Plan for Cognitive Loss, dated April 2015, indicated Resident #1 had impaired cognition related to dementia, [MEDICAL CONDITION] and weakness. Interventions included: promote dignity; converse with Resident #1; and ensure privacy while providing care. Resident #1's Care Plan for Activities of Daily Living (ADLs), dated April 2015, indicated Resident #1 had a self care deficit. Interventions included encourage him/her to accept the assistance necessary to ensure tasks were successfully completed. Resident #2's Care Plan for Cognitive Loss, dated 6/27/14, indicated Resident #2 had impaired cognition due to [DIAGNOSES REDACTED]. Resident #2's Care Plan for Activities of Daily Living, dated 6/27/14, indicated Resident #2 had a self care deficit and he/she required assistance with bed mobility, dressing, eating and toilet use. Resident #3's Care Plan for Cognitive Loss, dated 12/8/14, indicated Resident #3 had impaired cognitive skills. Resident #3's Care Plan for ADLs, dated 12/8/14, indicated he/she had a self care deficit. 1. The Surveyor interviewed CNA #4 at 3:20 P.M. on 6/11/15. CNA #4 said she has observed CNA #1 belittling Resident #2 and Resident #3 for months. In a written statement, dated 5/21/15, CNA #4 indicated the following. CNA #4 documented she saw CNA #1 verbally abuse Resident #2 and Resident #3. CNA #4 indicated CNA #1 yelled at them for soiling their briefs; CNA #1 said words to the effect, I am sick of changing their [***] ing[***]y briefs and would like to plug their asses. CNA #4 said she reported this to Nurse #2 about four or five months ago (January or February 2015). Surveyor interviewed Nurse #2 at 9:20 A.M. on 6/15/15. Nurse #2 told the Surveyor she could not recall receiving a report from CNA #4, but she said Nurse #3 remembered that CNA #4 had in fact, reported her concerns to Nurse #2. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 6/15/15. Nurse #3 said she recalled CNA #4 speaking to Nurse #2 about CNA #1. Nurse #3 said she heard Nurse #2 call the Director of Nurses to report CNA #4's concerns. Nurse #3 said she did not recall when this took place, but thought it was sometime in the winter. The Surveyor interviewed the Director of Nurses at 9:30 A.M. and throughout the day on 6/11/15. The Director of Nurses denied receiving a report from Nurse #2 about CNA #1. This is not consistent with the accounts of CNA #4 and Nurse #3. 2. The Surveyor interviewed CNA #3 at 12:38 P.M. on 6/11/15. CNA #3 said that on or about 5/6/15, he assisted CNA #1 with Resident #3's incontinence care. CNA #3 said CNA #1 was angry at Resident #3 and said words to the effect, stop[***]ing all over the place. In a written statement, dated 5/21/15, CNA #3 said he saw CNA #1 jerk residents around in an aggressive manner if they did not cooperate. CNA #3 wrote he heard CNA #1 say she did not like certain residents and that they were assholes. CNA #3 said he did not report his observations of 5/6/15 until after CNA #2 disclosed allegations of abuse on 5/21/15. 3. The Surveyor interviewed CNA #2 at 11:00 A.M. on 6/11/14. CNA #2 said on 5/20/15, she heard CNA #1 use profanities when speaking to Resident #1. CNA #2 said she heard CNA #1 call Resident #1 a [***] ing animal. CNA #1 said she heard CNA #1 tell Resident #1 he/she was disgusting and to shut up. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 6/15/15. Nurse #1 said she was administering medication outside Resident #1's room, when she heard CNA #1 tell Resident #1 to keep his/her mouth shut. Nurse #1 said she spoke to CNA #1 about the comment she made to Resident #1. There was no indication any other interventions were taken to protect residents from the actions of CNA #1. CNA #2 said on 5/20/15, she also observed CNA #1 providing incontinence care to Resident #2, CNA #2 said CNA #1 was angry and shoved Resident #2 to move him/her in the bed.

Based on record review and interviews, for one of five sampled residents (Resident #1) the Facility failed to ensure on 8/21/14, Resident #1 was provided appropriate rehabilitative therapy when Resident #1 was burned with a [MEDICATION NAME] pack treatment (moist heat) that was not ordered by the Physician The Physical Therapy Assistant (PTA) said he applied moist heat to Resident #1's right knee without a physician's order; the application of the heat was not part of the skilled therapy plan of care. Findings include: Resident #1 clinical record, dated 8/15/14, included orders for a physical therapy evaluation and treatment that included skilled physical therapy services that included therapeutic activity, neuromuscular re-education, gait training, caregiver education as indicated. The incident report, dated 8/22/14, indicated that the Unit Manager observed 2 small blisters over the bony prominence of Resident #1's knee. The incident report indicated Resident #1 said a man put a hot pack on his/her right knee last night (8/21/14). The Surveyor interviewed the Unit Manager at 11:00 A.M. on 9/9/14. The Unit Manager said she applied a topical medication to Resident #1's left leg when Resident #1 complained of pain in his/her right knee. The Unit Manager said she observed 2 small blisters on each side of the knee. The Unit Manager said Resident #1 told her a man put a hot pack on his/her right knee. The Surveyor interviewed the PTA at 1:00 P.M. on 9/9/14. The PTA said on 8/21/14, he went to treat Resident #1, who complained of right knee stiffness. The PTA said he applied a moist heat treatment of [REDACTED].#1's right knee. The PTA said there was no physician's order for the [MEDICATION NAME] pack, because it was not a skilled physical therapy treatment. The PTA said he used padding around the [MEDICATION NAME] pack that equaled 12 layers, checked Resident #1's skin before and after the 10 minute treatment, and there was no evidence of a burn. The PTA said Resident #1 felt better and was able to ambulate during therapy. The PTA said the next day, he was notified by The Rehabilitation Manager that Resident #1 sustained a burn from the [MEDICATION NAME] pack. The internal investigation, dated 8/28/14, indicated the small blisters were located on the lateral and medial sides of the knee that measured 1.5 centimeters (cm) x 2 cm and lateral blister measured 1 cm x 1 cm. The internal investigation indicated on 8/22/14, the Physician ordered skin prep to the areas, and on 8/25/14, both blisters were reabsorbed, and Resident #1's skin was intact. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. and 1:30 P.M. on 9/9/14. The DON said she observed the two blisters on Resident #1's right knee, within a few days both areas were healed with no further issues.

Based on record review and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure Physical Therapy Assistant (PTA) followed acceptable standards of practice and ensured the application of heat was performed in accordance with Facility policy and with a physician's order, and only with approval of the supervising physical therapist. On 8/21/14, PTA applied a moist heat treatment or [MEDICATION NAME] pack to Resident #1's right knee. PTA said there was no physician's order for the [MEDICATION NAME] pack, because it was not a skilled treatment. In addition, the PTA failed to cover the [MEDICATION NAME] pack according to the policy, or document the application of the heat. On 8/22/14, Resident #1 was noted to have blistered areas at the site where the heat was applied. Findings include: According to 259 CMR 5.00, the required supervision of physical therapy assistants required, at a minimum, that the supervising physical therapist perform the initial assessment, develop the plan of care, select and delegate appropriate tasks for the plan; re-evaluate and adjust the plan of care when necessary. In addition, "physical therapy assistants may not initiate or alter a treatment program without prior evaluation by and approval by the supervising physical therapist." Resident #1 clinical record, dated 8/15/14, included orders for physical therapy evaluation and treatment that included skilled physical therapy services that included therapeutic activity, neuromuscular re-education, gait training, and caregiver education as indicated. The incident report, dated 8/22/14, indicated that the Unit Manager observed 2 small blisters over the bony prominence of Resident #1's knee. The incident report indicated Resident #1 said a man put a hot pack on his/her right knee last night (8/21/14). The Surveyor interviewed the PTA at 1:00 P.M. on 9/9/14. The PTA said on 8/21/14, he went to treat Resident #1, who complained of right knee stiffness. The PTA said he applied a moist heat treatment of [REDACTED].#1's right knee. The PTA said there was no physician's order for the [MEDICATION NAME] pack, because it was not a skilled physical treatment. The PTA said he used two-ply padding around the [MEDICATION NAME] pack that equaled 12 layers, checked Resident #1's skin before and after the 10 minute treatment, and there was no evidence of a burn. The PTA said Resident #1 felt better and was able to ambulate during therapy. The PTA said the next day, he was notified by The Rehabilitation Manager that Resident #1 sustained a burn from the [MEDICATION NAME] pack. The PTA said he did not document any information regarding the [MEDICATION NAME] treatment. The [MEDICATION NAME] policy indicated that appropriate layers of toweling should be used to equal 10-14 layers to prevent burns. The policy indicated the following precautions should be used: -maintain temperature of machine between 150 to 170 degrees -make sure hot pack is secure -instruct resident not to move [MEDICAL CONDITION] occur -do not leave resident unattended and adjust toweling as needed -supervise care The Surveyor interviewed the Rehabilitation Manager at 10:00 A.M. on 9/9/14. The Rehabilitation Manager said there was no physician's order for use of the [MEDICATION NAME] pack, and the padding used by the PTA equaled approximately 4 to 8 layers, not the required 10-14 layers of padding to prevent burns. The temperature log, dated 8/21/14, indicated the temperature of the [MEDICATION NAME] machine was 160 degrees. The internal investigation, dated 8/28/14, indicated the small blisters were located on the lateral and medial sides of the knee that measured 1.5 centimeters (cm) x 2 cm and lateral blister measured 1 cm x 1 cm. The internal investigation indicated on 8/22/14, the Physician ordered skin prep to the areas, and on 8/25/14, both blisters were reabsorbed, and Resident #1's skin was intact. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. and 1:30 P.M. on 9/9/14. The DON said she observed the two blisters on Resident #1's right knee, within a few days both areas were healed with no further issues.

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure Resident #1, who was assessed to be at high risk for falls, received necessary supervision and assistance to prevent falls. At 6:30 P.M. on 3/31/14, Resident #1 had an unwitnessed fall and sustained a bruise to the right side of his/her head and a fractured right hip. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessement, dated 1/18/14, indicated that his/her cognitive patterns were moderately impaired, he/she required extensive assistance to transfer between surfaces and he/she used a wheelchair for mobility. Resident #1's care plan, initiated 1/24/13 and most recently reviewed 3/12/14 indicated that he/she was at risk for falls due to dementia and decreased safety awareness. Resident #1's care plan interventions included pressure alarm when Resident #1 sat in a chair and a clip alarm at all times. Resident #1 was not interviewed by the Surveyor due to Resident #1's cognitive impairment. The Surveyor interviewed CNA #1 at 4:00 P.M. on 4/19/14. CNA #1 said she routinely cared for Resident #1 and was aware that Resident #1 required a pressure alarm when he/she sat in a chair. CNA #1 said that she was assigned to care for Resident #1 during the 7:00 A.M. to 3:00 P.M. shift on 3/12/14 and, when she assisted Resident #1 out of bed in the morning, there was no pressure alarm present in Resident #1's wheelchair. CNA #1 said she applied a clip alarm to Resident #1's wheelchair but could not find a pressure alarm to use. CNA #1 said that while she was still looking for a pressure alarm, Resident #1 attended an activity and fell . The Facility Incident Report, dated 3/12/14, indicated Resident #1 fell without injury at 10:10 A.M. during an activity. CNA #1 said that, on 3/31/14, when she assisted Resident #1 out of bed in the morning, the pressure alarm was not present in Resident #1's wheelchair. CNA #1 said she applied the clip alarm to Resident #1 in the wheelchair but mentioned the absence of the pressure alarm to a nurse although she could not recall which nurse. The Surveyor interviewed CNA #3 at 3:45 P.M. on 4/18/14. CNA #3 said she was assigned to care for Resident #1 during the 3:00 P.M. to 11:00 P.M. shift on 3/31/14, and, assisted him/her to the bathroom before dinner. CNA #3 said she recalled that Resident #1 had a clip alarm in place, but did not know whether Resident #1 had a pressure alarm in the wheelchair. CNA #3 said that although residents' required alarms were written on the assignment, she did not check to see which alarms Resident #1 required. The Surveyor checked Resident #1's written assignment for 3/31/14 which indicated Resident #1 used a pressure alarm and a clip alarm when seated in a chair. The Surveyor interviewed CNA #2 at 10:45 A.M. on 4/17/14. CNA #2 said he transferred Resident #1 from his/her wheelchair into a recliner chair in front of the television after dinner on 3/31/14 as was Resident #1's customary routine. CNA #2 said that although Resident #1 usually had a pressure alarm and a clip alarm, only the clip alarm was present. CNA #2 said that he applied the clip alarm to Resident #1 in the recliner chair. The Facility Incident Report completed at 6:30 P.M. on 3/31/14 indicated that Resident #1 had an unwitnessed fall and was found with a bruised area on the right side of his/her head and complained of hip pain. The Facility Internal Investigation Report indicated Resident #1 was transferred to the hospital and diagnosed with [REDACTED].

Based on interview and record review, for one on three sampled residents (Resident #1), the Facility failed to ensure on 3/12/14, Certified Nursing Assistant (CNA) #1 applied a pressure alarm in accordance with the care plan. On 3/31/14, CNA's #1, #2 and #3 failed to apply a pressure alarm in accordance with the care plan and at 6:30 P.M., Resident #1 was found on the floor next to a recliner chair after an unwitnessed fall with a bruised area on the right side of his/her head and a fractured right hip. Findings included: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessement, dated 1/18/14, indicated that his/her cognitive patterns were moderately impaired, he/she required extensive assistance to transfer between surfaces and he/she used a wheelchair for mobility. Resident #1's care plan, initiated 1/24/13 and most recently reviewed 3/12/14, indicated that he/she was at risk for falls due to dementia and decreased safety awareness. Resident #1's care plan interventions included pressure alarm when Resident #1 sat in a chair and a clip alarm at all times. Resident #1 was not interviewed by the Surveyor due to Resident #1's cognitive impairment. The Surveyor interviewed CNA #1 at 4:00 P.M. on 4/19/14. CNA #1 said on 3/31/14, when she assisted Resident #1 out of bed in the morning, the pressure alarm was not present in Resident #1's wheelchair. CNA #1 said she applied the clip alarm to Resident #1 in the wheelchair but mentioned the absence of the pressure alarm to a nurse, but could not recall which nurse. The Surveyor interviewed CNA #3 at 3:45 P.M. on 4/18/14. CNA #3 said she was assigned to care for Resident #1 during the 3:00 P.M. to 11:00 P.M. shift on 3/31/14, and, assisted him/her to the bathroom before dinner. CNA #3 said she recalled that Resident #1 had a clip alarm in place, but did not know whether Resident #1 had a pressure alarm in the wheelchair. CNA #3 said although residents' who required alarms were written on the assignment, she did not check to see which alarms Resident #1 required. The Surveyor checked Resident #1's written assignment for 3/31/14 which indicated Resident #1 used a pressure alarm and a clip alarm when seated in a chair. The Surveyor interviewed CNA #2 at 10:45 A.M. on 4/17/14. CNA #2 said he transferred Resident #1 from his/her wheelchair into a recliner chair in front of the television after dinner on 3/31/14 as was Resident #1's customary routine. CNA #2 said that although Resident #1 usually had a pressure alarm and a clip alarm, only the clip alarm was present. CNA #2 said that he applied the clip alarm to Resident #1 in the recliner chair. The Facility Incident Report completed at 6:30 P.M. on 3/31/14 indicated that Resident #1 had an unwitnessed fall and was found with a bruised area on the right side of his/her head and complained of hip pain. The Facility Internal Investigation Report indicated Resident #1 was transferred to the hospital and diagnosed with [REDACTED].