Every finding on record at Eliot Center for Health and Rehabilitation

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of opioid dependency and alcohol use disorder, the facility failed to ensure supportive services to maintain his/her sobriety were offered and available.Findings include:Review of the facility's policy, titled Substance Use Disorder (SUD-a medical condition that is defined by the inability to control the use of a particular substance(s) despite harmful consequences), with a revision date of 11/2025, included the following:-The purpose of this policy is to identify residents prior to admission and discharge processes as they relate to substance use disorder. To identify all appropriate diagnoses or specific services needed as they relate to the substance abuse/use on addiction and to determine risk for relapse and the level of supervision needed.-Social Services will work on setting up support groups in collaboration with the Activities department to provide adequate support to the residents, as allowed by the resident.-Social Services staff will work on setting up other more specific and relevant support services, as allowed by the resident.-Social Services staff will create a plan of care based on specific resident needs to ensure adequate supports are in place.Review of the facility's policy for Comprehensive Care Plans, with a revision date of 07/2023, indicated the following:-Policy: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident.-Each resident's comprehensive care plan is designed to:*Aid in preventing or reducing declines in the resident's functional status and/or functional levels.*Enhance the optimal functioning of the resident by focusing on a rehabilitative program (when appropriate)*Reflect currently recognized standards of practice for problem areas and conditions.Resident #1 was admitted to the facility in April 2026 diagnoses included opioid dependence, alcohol abuse, hepatic encephalopathy (occurs when the liver cannot adequately filter toxins, particularly ammonia, from the blood, allowing them to reach the brain and disrupt its function), and alcoholic cirrhosis (scarring) of liver with ascites (fluid in the abdomen).Review of Resident #1's Substance Use Assessment, dated 04/28/26, indicated the following:-Opioid use: in remission-Alcohol: recent use-Methadone is prescribed to assist with current Substance Use Disorder-Substance Use History: Active user (used within 0-3 months)Review of Resident #1's Substance Use Disorder Care Plan, initiated on 04/28/26, indicated it included the following intervention(s):-Offer/encourage Alcoholics Annonymous (AA)/Narcotics Annonymous (NA) meeting participation.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 05/04/26, indicated he/she was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, 13-15 suggests cognitively intact).Review of Resident #1's Psychiatric Nurse Practitioner (PNP) Evaluation, dated 05/18/26, indicated that Resident #1 openly discussed his/her history of substance abuse and long history of alcohol abuse. The Evaluation indicated Resident #1 stated that participation in Alcoholics Anonymous had been beneficial in his/her recovery.Further review of the Evaluation indicated the Plan included to encourage Resident #1's ongoing participation in recovery-based supports and utilization of healthy coping skills.Review of Resident #1's medical record indicated there was no documentation to support that he/she was offered or provided an opportunity to attend Alcoholics Annonymous meetings, in person or virtually, during his/her stay at the facility.During a telephone interview on 06/10/26 at 8:25 A.M., Psychiatric Nurse Practitioner (PNP) said she had visited Resident #1 at the facility on 05/18/26 and 05/28/26. The PNP said it was not her responsibility to have facilitated Resident #1's participation in AA meetings. The PNP said it was the facility's responsibility to offer AA meetings.During a telephone interview on 06/11/26 at 1:54 P.M., Mental Health Clinician (MHC) #1 said she had visited Resident #1 at the facility on 05/19/26 and 05/27/26. MHC #1 said it was the facility's responsibility to facilitate Resident #1's participation in AA meetings.During an interview on 06/09/26 at 1:10 P.M., Social Worker (SW) #1 said she had visited Resident #1 at the facility on multiple occasions and his/her goal was to be discharged to a transitional SUD house. SW #1 said that it was the Psychiatric Services responsibility to offer SUD services and support. SW #1 said she did not collaborate with Psychiatric Services regarding the care and services for Resident #1. SW #1 said if she had collaborated with Psychiatric Services related to Resident #1's care, she would have documented it in her progress notes.During a telephone interview on 06/10/26 at 3:55 P.M., the Administrator said she thought it was the Psychiatric Services responsibility to offer and facilitate AA meetings for Resident #1.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete, accurate, and accessible medical records, when his/her psychiatric service progress notes were not readily accessible and not included in his/her medical record.Findings include:Review of the facility's policy, titled Charting and Documentation, with a revision date of 07/2023, included the following:-All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.-The following information is to be documented in the resident medical record:*Treatments or services performed.Resident #1 was admitted to the facility in April 2026 diagnoses included opioid dependence, alcohol abuse, hepatic encephalopathy (occurs when the liver cannot adequately filter toxins, particularly ammonia, from the blood, allowing them to reach the brain and disrupt its function), and alcoholic cirrhosis (scarring) of liver with ascites (fluid in the abdomen).During the survey on 06/09/26, the surveyor requested copies of all Resident #1's Psychiatric Progress Notes.During a telephone interview on 06/10/26 at 3:55 P.M., the Administrator asked the surveyor if she had read the Mental Health Clinician's (MHC) progress notes for Resident #1. The surveyor then informed the Administrator that the MHC's progress notes were not in Resident #1's Electronic Medical Record (EMR) nor were they provided during the survey.Resident #1's Mental Health Clinician visit notes were faxed to the surveyor on 06/11/26 (two days after the onsite survey) for review.Review of Resident #1's Nursing Progress Note, dated 05/29/26, indicated he/she eloped out of a third-floor window.Review of Resident #1's Comprehensive [Psychotherapy] Assessment (progress note), with date of service documented as 05/27/26, indicated he/she had jumped out of a second story window and was transferred to the hospital. Further review of the Assessment indicated it was signed and dated by Mental Health Clinician (MHC) #1 on 06/10/26 at 9:31 P.M.During a telephone interview on 06/11/26 at 1:54 P.M., Mental Health Clinician (MHC) #1 said that she visited Resident #1 at the facility on 05/19/26 and 05/27/26. MHC #1 said she had written Resident #1's progress notes for the visit on 05/27/26 the night before [6/10/26] this interview because the Administrator had requested, she write a note.MHC #1 said she had not written Resident #1's progress notes immediately following the visit and mistakenly wrote in his/her Comprehensive Assessment/progress note for 5/27/26, that he/she had jumped out of a window when that had not yet happened. MHC #1 said she was supposed to have a progress note relate to her visits completed and signed within 48 to 72 hours following a clinical visit.During a telephone interview on 06/11/26 at 2:23 P.M. the Administrator said it was her expectation that all medical records were accurate and accessible.

Based on observations, interviews, and records reviewed, for one of three sampled residents (Resident #1), who resided on a secured unit, had a guardianship in place, and whose care plan indicated he/she was to remain within the Facility unless supervised, the Facility failed to ensure they provided an adequate level of staff supervision to maintain his/her safety and prevent an incident of elopement.Findings include:The Facility Policy, titled Elopement of a Resident, last revised July 2025, indicated that if a resident was identified as at risk for wandering, elopement, or other safety concerns, the resident's care plan would include strategies and interventions to maintain his/her safety.Resident #1 was admitted to the Facility in November 2023, diagnoses included dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/14/26, indicated he/she had a Guardian, ambulated independently, and required physical assistance with Activities of Daily Living (ADL) care.Review of the Facility's Internal Investigation, dated 03/17/26, indicated that on 03/17/26 at around 3:00 P.M., Resident #1 was identified as missing and an elopement code was immediately called overhead. The Investigation indicated staff searched the Facility, including the interior and exterior grounds, with negative results. The Investigation indicated that about 45 minutes later, staff and local police located Resident #1 at his/her former home address, about 2 miles from the Facility.The Investigation indicated Resident #1 was sent to the local Emergency Department for evaluation, and returned to the Facility the same day at around 6:00 P.M., with no injuries. The Investigation indicated Resident #1's care plan was updated following the incident.During an interview on 04/21/26 at 3:00 P.M., Certified Nurse Aide (CNA) #2 said he saw Resident #1 around 2:30 P.M. at the nurse station asking how to leave from the Facility. CNA #2 said Resident #1 routinely wandered throughout the unit; however, he/she was not known to exhibit exit-seeking behavior, and at that time, CNA #2 said he did not think he/she would leave the Facility.During a telephone interview on 04/28/26 at 1:00 P.M., Nurse #1 said he saw Resident #1 around 2:40 P.M. at the nursing station interacting with staff. Nurse #1 said that around 3:00 P.M., during his final clinical rounds, he noticed Resident #1 was missing and immediately activated the elopement code overhead.During an interview on 04/21/26 at 12:15 P.M., the Administrator said staff on Resident #1's unit had not observed exit-seeking behavior prior to the incident. The Administrator said the unit exit doors were equipped with alarms and required a code to open, and the rear exit doors also had audible alarms.The Administrator said the Facility presumed Resident #1 may have entered the elevator with a visitor who had access to the code and then exited the building. The Administrator said staff were re-educated not to share elevator or door alarm codes with visitors or outside consultants.During an interview on 04/21/26 at 1:30 P.M., the Director of Nurses (DON) said that the Facility had not initiated an elopement assessment or care plan interventions for Resident #1, even though staff observed Resident #1 asking how to leave the Facility prior to the incident. The DON said Resident #1 had no prior history of exit-seeking, and staff assumed he/she would not remember how to leave the unit.On 04/21/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a Plan of Correction, effective 04/02/26, which addressed the identified area(s) of concern, as evidenced by:A. On 03/17/26, following evaluation in the local Emergency Department, Resident #1 returned to the Facility later the same day, and had no injuries.B. On 03/17/26 the Facility completed assessments for Resident #1 for elopement risk, functional abilities, goals, and a nursing evaluation.C. The Facility initiated one-to-one staff monitoring to ensure Resident #1's safety and applied a Wander Guard to his/her left ankle.D. On 03/18/26, the Facility updated Resident #1's care plan interventions to include the use of a Wander Guard, with placement and function checks every shift.E. On 03/18/26, Resident #1 was evaluated by the Facility Nurse Practitioner and Facility Social Worker for ongoing assessment and support.F. On 03/18/26, the Facility's alarm company assessed the door alarms and determined they were functioning appropriately.G. On 03/18/26 and ongoing, the Facility initiated random Leadership audits of staff response times to door and elevator alarm sounds.H. From 03/18/26 through 03/31/26, all Facility staff were educated by the Director of Nurses (DON) and the Staff Development Coordinator on the following: Identifying exit-seeking behaviors and management, including reporting behaviors to clinical management. Reassessing elopement risk and implementing preventative measures. Safety checks, door alarm response procedures, elevator alarm/code response, and not sharing alarm codes. I. From 03/18/26 through 04/01/26, the Maintenance Director completed audits of all exit doors and elevator alarms and secured all windows on the unit.J. During the March 2026 monthly Quality Assurance and Performance Improvement (QAPI) meeting, the committee reviewed and discussed the incident, identified an area of concern, and developed a corrective action plan.K. The QAPI committee will continue to monitor this concern area for several months to ensure continued substantial compliance.L. The Administrator and/or designee are responsible for overall compliance.

Based on interviews, and record reviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - notice issued to beneficiaries so they may decide if they wish to continue receiving skilled services that may not be paid for by Medicare and assume financial responsibility), and a paper copy of the Notice of Medicare Non-Coverage (NOMNC - notice issued to beneficiaries before the end of Medicare covered Part A skilled services) for two Residents (#33 and #78) of three applicable residents reviewed for beneficiary notices, out of a total sample of 20 residents.Specifically, the facility failed to:For Resident #33, issue a SNF ABN as required, to the Resident's activated Health Care Proxy (HCP - the person elected to make healthcare decisions for you if you cannot do so for yourself) when the effective date of coverage for skilled services was ending, and provide evidence that a paper copy of the NOMNC was issued to the Resident's activated HCP as required, after telephone notification by the facility of the end of skilled services was conveyed to the activated HCP. 2. For Resident #78, issue a SNF ABN as required, to the Resident's activated HCP when the effective date of coverage for skilled services was ending and provide evidence that a paper copy of the NOMNC was issued to the Resident's activated HCP as required, after facility telephone notification of skilled services ending was conveyed to the activated HCP. Findings include: Review of the Form Instructions for Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055 (2024), required the facility to notify and explain to the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of the Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, indicated the NOMNC should be issued by the facility to the beneficiary at least two days before the end of a Medicare Part A stay.The NOMNC informs the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO - an independent reviewer authorized by Medicare to review the decision to end these services).Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the NOMNC, with the required beneficiary-specific information inserted, at the time of notice delivery. The NOMNC may be delivered to a beneficiary's representative. Review of the facility policy, Subject: Medicare Denials - Advance Beneficiary Notice, dated 9/2025, indicated:-Upon coming off Medicare A and remaining in the facility, the MDS Coordinator will issue the Advanced Beneficiary Notice.prior to the last day of coverage. Review of the facility policy, Subject: Notice of Medicare Non-Coverage, dated 2/2025, indicated:-The (Skilled Nursing Facility) SNF (provider) is responsible for delivering the notice in person (preferred) or by other valid means (e.g., phone with documentation, followed by mailing). 1.Resident #33 was admitted to the facility in September 2025 with diagnoses including Alzheimer's Disease, difficulty walking and muscle weakness. Review of Resident #33's clinical record indicated:the Minimum Data Set (MDS) assessment dated [DATE], the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points.the Resident was not his/her own responsible party and their HCP was activated 8/22/25.the Resident's Medicare Part A Skilled Services started 10/1/25.the Resident's last covered day of Part A Skilled Services ended 10/23/25.the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.the Resident remained in the facility.there was no evidence the SNF ABN had been issued to the Resident's activated HCP.the facility staff person telephoned the Resident's activated HCP on 10/21/25 to notify them of the NOMNC, including the last covered day of Part A Skilled Services, and their right to appeal and appeal deadline. There was no evidence in the clinical record that a paper copy of the NOMNC was provided to the Resident #33's activated HCP. 2.Resident #78 was admitted to the facility in January 2026 with diagnoses including Acute Respiratory Failure, Pneumonia, non-displaced fracture of head of radius and unspecified dementia. Review of Resident #78's clinical record indicated:the MDS assessment dated [DATE], the Resident was severely cognitively impaired in both short and long term memory as evidenced by a BIMS score of 99.the Resident was not his/her own responsible party and their HCP was activated 1/25/25.the Resident received Medicare Part A Skilled Services starting 1/23/26.the Resident's last covered day of Part A Skilled Services ended 3/14/26.the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.the Resident remained in the facility.there was no evidence the SNF ABN had been issued to the Resident's activated HCP.the facility staff person telephoned the Resident's activated HCP on 3/12/26 to notify them of the NOMNC, including last covered day of Part A Skilled Services, right to appeal and appeal deadline, but there was no evidence in the clinical record that a paper copy of the NOMNC was provided to the Resident's activated HCP. During an interview on 4/13/26 at 3:18 P.M., MDS Nurse #1 and Social Worker #1 said that the SNF ABN had not been issued to Resident #33 and Resident #78's activated HCPs, but the SNF ABNs should have been issued to the Residents activated HCPs. MDS Nurse #1 and Social Worker #1 also said that they could not provide evidence that a paper copy of the NOMNC was provided to the Residents activated HCPs.

Based on observation and interview, the facility failed to provide an ongoing program of group activities designed to meet the interests of and support the physical, mental, and psychological well-being of residents on two Units (3 and 4) out of three units.Finding include: Review of the Activities Calendar posted on the bulletin board indicated the following activities were scheduled on 4/9/26:-9:00 A.M. - Morning Greeting-10:00 A.M. - Coffee Social-10:30 A.M. - Scattergories-11:00 A.M. - Seated Stretch-2:00 P.M. - Balloon Pants Game On 4/9/26 from 10:20 A.M. to 10:58 A.M., on Unit #4, the surveyor observed the following:-The scheduled activity programs (Coffee Social and Scattergories) were not occurring on the unit.-Activity Staff #1 was distributing the Daily Chronicle in resident rooms.-Six Residents were seated in wheelchairs parked against a wall and another resident was wandering in the hallway.-No staff were engaging with the seven residents. During an interview on 4/9/26 at 10:58 A.M., the surveyor observed a resident seated alone in the dining room on Unit 4 holding a Daily Chronicle sheet. The resident said, There was nothing interesting in [the Daily Chronicle], there were no activities happening, and there was usually nothing to do. The resident further said that it had been like that for a while, and they do not have enough staff. On 4/9/26 at 11:07 A.M. in the main dining/activity room, the surveyor observed five residents sitting at tables and the scheduled activity Seated Stretch did not occur. On 4/9/26 at 2:45 P.M. in the main dining/activity room, the surveyor observed five residents sitting at tables with one activity staff present. The scheduled Balloon Pants Game did not occur. Review of the Activities Calendar posted on the bulletin board indicated the following activities were scheduled on 4/10/26:>9:00 A.M. - Morning Greeting>10:00 A.M. - Coffee Social>10:30 A.M. - Name 5>11:00 A.M. - Group Exercise>2:00 P.M. - Create your own puzzle>3:00 P.M. - Rhyme, Rhyme, Wrong! During a continuous observation on 4/10/26 from 8:05 A.M. to 10:37 A.M on Unit 3, the surveyor observed the following:-9:24 A.M. - Five residents ambulating in the hallway, including one resident attempting to access the elevator requiring staff to redirect him/her and another resident asking about flights out of Boston. No staff were redirecting the residents or engaging them in any group activity.-10:00 A.M.- Two of the five residents continued to wander on the unit.-the scheduled activity programs, (Morning Greeting, Coffee Social, and Name 5) were not occurring on the unit.-Resident #2 was seated in small dining room at a table and facing the wall and was loudly calling out, with no engagement in activity.-Resident #74 was wandering on the unit and stating, What do I do? and There is nothing to do. No engagement in group activity was observed. During an interview on 4/10/26 at 10:25 A.M., Activity Staff #1 said that she is a new staff member who started 13 days prior and had been on her own in the Activity Department until the current Activity Director started 3 days prior. Activity Staff #1 said that she and another CNA were trying to coordinate activities, but they were unable to execute the activity programs on the schedule. She said the facility will offer a large group program around 10:15/10:30 each morning and at 2:00 P.M. in the large dining and activity room downstairs. Activity Staff #1 said that there are not enough staff in the activities department to do activity programs on each of the units. During an interview on 4/13/26 at 10:37 A.M., Resident #96 and Member of the Resident Council, said the facility went awhile without activities because there was no one working in the activity department. The Resident said that there are no activities on the weekend and the Resident Council has discussed wanting more varied activities because it gets boring doing the same things. During an interview on 4/13/26 at 2:24 P.M., the Administrator and the Activities Director reported the Activity Director began employment on 4/8/26 and Activity Staff #1 began on 3/17/26. The Administrator said there was staff turnover in the previous Activity Department over the course of a few months and one CNA was facilitating activities during that time. The Administrator said currently there are no activity programs occurring on the Units and the only activities offered on the Units are one to one visits, nail care, room visits, and music therapy due to staffing challenges.

Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of two nurses observed, made two errors out of 34 opportunities, for a medication error rate total of 5.88%, affecting one Resident (#30) out of three residents observed.Specifically, for Resident #30, the facility failed to: -ensure that a blood pressure reading was obtained per Physician order, prior to administering Amlodipine (medication to treat high blood pressure) medication, putting the Resident at risk for hypotension (extremely low blood pressure) and related complications.-ensure that MiraLAX (medication to treat constipation) medication was administered as ordered, when the medication was not given, by signed off as given by staff, putting the Resident at risk for constipation. Findings include: Review of the facility policy titled Administering Medications, undated, indicated:-The following is checked/verified for each resident prior to administering medications: >vital signs, if necessary.-Medications are administered in accordance with prescriber orders, including any required time frame. Resident #30 was admitted to the facility in September 2025, with diagnoses including Hypertension, Anxiety, and Adult Failure to Thrive. Review of Resident #30's April 2026 Physician orders indicated:-Amlodipine 10 mg tablets - give one tablet my mouth one time a day for Hypertension (high blood pressure), hold for systolic blood pressure (SBP) less than 100.-MiraLAX Powder 17 grams (gm), give one scoop by mouth one time a day for constipation, mix in 6-8 ounces of water or juice, hold for loose stools. On 4/9/26 at 7:48 A.M., the surveyor observed the following during medication administration for Resident #30 by Nurse #1:*Nurse #1 prepared and administered the following medication:-Amlodipine 10 milligram (mg) tablet, 1 tablet.-Nurse #1 did not obtain a blood pressure reading prior to administering the Amlodipine medication.-did not administer MiraLAX medication to the Resident. Review of Resident #30's April 2026 Medication Administration Record (MAR), indicated:*Nurse #1 had electronically signed that she administered the following medications on 4/9/26:- Amlodipine 10 mg tablet.-MiraLAX Powder 17 grams. During an interview on 4/9/26 at 8:28 A.M., Nurse #1 said she did not obtain Resident #30's blood pressure reading before administering the Amlodipine medication because the previous shift usually obtains the Residents' vital signs. Nurse #1 said the computer did not alert her to enter a blood pressure reading. Nurse #1 said if there was no blood pressure documented the computer would not have allowed her to move on to another resident. Nurse #1 said she had no blood pressure reading for Resident #30. Nurse #1 further said she should have obtained Resident #30's blood pressure before administering the Amlodipine medication but she did not. Nurse #1 also said there was no MiraLAX medication available to be administered in her medication cart, but she needed to sign the MAR to indicate that she had administered the MiraLAX medication so she could continue to the next resident. Nurse #1 said she should not have electronically signed that the MiraLAX medication was administered when she had not administered it. During an interview on 4/9/26 at 8:55 A.M., the Assistant Director of Nursing (ADON) said Nurse #1 should have followed the Physician's order to obtain Resident #30's blood pressure reading before administering the Amlodipine medication. The ADON further said Nurse #1 should not have signed off the MiraLAX medication as administered when the medication was not available in the medication cart.

Based on observation, and interviews, the facility failed to adhere to infection control standards of practice, for one Resident (#14) out of a total sample of 20 residents, and on one Unit (Fourth Floor) out of three units observed. Specifically, the facility failed to:1. ensure that Resident #14's foley catheter drainage bag remained off the floor to prevent contamination putting the Resident at risk for catheter associated infections.2. ensure that ice in an ice chest was distributed to the residents on the Fourth Floor Unit under sanitary conditions.3. ensure the housekeeping staff adhered to appropriate infection control practices when cleaning consecutive rooms which included a room with contact precautions on the Fourth Floor Unit. Findings include:1. Review of the facility policy titled Catheter Care, Urinary, undated, indicated: -Infection Control: be sure the (urinary) catheter tubing and drainage bag are kept off the floor. Resident #14 was admitted to the facility in April 2024 with diagnoses including hydronephrosis with renal and ureteral calculus obstruction, retention of urine, and Acute Kidney Failure, Unspecified. Review of Resident #14's Physician's orders for April 2026 indicated the Resident had Physician's orders for the following treatments: -Foley catheter care every shift monitor for hematuria and placement, dated 11/18/25. Review of the April 2026 Treatment Administration Record (TAR) indicated Resident #14 was receiving foley catheter care as ordered by the Physician. On 4/8/26 at 10:50 A.M., the Resident #14's foley catheter drainage bag was observed on the floor next to the Resident's bed. During an interview at the time, Resident #14 said he/she was unaware the urinary drainage bag was on the floor. On 4/9/26 at 8:59 A.M., the surveyor observed Resident #14 asleep in bed and the urinary drainage bag was laying on the floor next to the Resident's bed. On 4/9/26 at 10:34 A.M., the surveyor observed a Nurse entering Resident #14's room and closing the door. The Nurse was then observed exiting Resident #14's room and the surveyor observed the urinary drainage bag laying on the floor next to the Resident's bed as the Nurse exited the room. During an interview on 4/9/26 at 10:45 A.M., with the District Coordinator of Education, Resident #14's foley catheter bag was observed laying on the floor next to the Resident's bed. The District Coordinator of Education said the Nurse (who was in the room) should have noticed the urinary catheter bag on the floor and should have picked up and positioned the urinary drainage bag off the floor. The District Coordinator of Education said urinary catheter drainage bags should always be off the floor to prevent the spread of infection. During an interview 4/14/26 at 10:00 A.M., the Director of Nursing (DON) said Resident #14's urinary catheter bag should never be on the floor because it was an infection control issue. 2. On 4/9/26 at 8:44 A.M. the surveyor observed the following on the Fourth Floor Unit: -A resident was walking behind the nursing station holding two cups. The resident placed the two cups on an ice cart stored behind the nursing station. -The resident opened the ice chest and took the scoop from the holder with his/her bare right hand and began banging on the ice with the scoop. -The resident then took a scoop of ice from the chest, removed the ice from the scoop with his/her bare left hand and put the ice in the two cups. The resident dropped some of the ice directly on top of the ice cart and picked up the ice off the cart and put it in the two cups. -The resident proceeded to bang on the ice with the scoop and remove ice from the scoop with his/her bare hands two more times while picking up ice that was dropped on the top of the ice cart and placing it in the two cups. -During the same time the resident was accessing the ice chest, two staff members went behind the nursing station and walked by the resident as he/she was accessing the ice chest and did not redirect the resident away from the ice chest or attempt to assist the resident. -The resident was then observed putting the scoop back in its holder and walking back down the hall with the two cups. The resident was not observed sanitizing his/her hands at any time during the observation. During an interview on 4/9/26 at 9:24 A.M., the Assistant Director of Nursing (ADNS) said the residents should not be behind the nursing station accessing the ice. The ADNS said if staff sees the residents accessing the ice they should be redirecting the resident away from the ice chest and assisting residents with getting the ice from the ice chest. The ADNS said the residents accessing the ice chest on their own is an infection control issue and can cause the spread of infection to other residents. During an interview on 4/14/26 at 10:16 A.M., the Director of Nursing (DON) said residents should not be behind the nursing station accessing the ice chest on their own. The DON said residents accessing the ice chest on their own creates an infection control issue. 3. On 4/14/26 at 9:45 A.M., the surveyor observed housekeeping staff (HSK) #2 mop a resident's room (414) with a Contact Precaution sign outside of the door indicating that anyone entering the room should wear a gown and gloves. HSK #2 was not observed wearing a gown. HSK #2 completed mopping room [ROOM NUMBER] and then moved onto to room [ROOM NUMBER]. HSK #2 was observed mopping the floor of room [ROOM NUMBER] with the same water used in room [ROOM NUMBER] and continued to the other side of the hallway with the same water and mopped room [ROOM NUMBER] that was not identified as a precaution room. During an interview on 4/14/26 at 10:00 A.M., HSK #2 said she cleaned three rooms and changed the water. HSK #2 said she was aware room [ROOM NUMBER] was a Contact Precaution room. During an interview on 4/14/26 at 10:15 A.M., the Infection Preventionist (IP) said the Contact Precaution room [ROOM NUMBER] was a resident who had been diagnosed with Clostridium Difficile (C-DIFF – bacterial infection causing severe loose stools that is contagious). The IP said HSK #2 should have worn a gown before cleaning the room and should have cleaned the contaminated room last. The IP said HSK #2 should not have cleaned another room with the same water. During an interview on 4/14/26 at 10:30 A.M., the Housekeeping Manager said the requirement is for the housekeeping staff to clean the contaminated room last and not to clean another room with the same water.

Based on interview, and record review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care planning process for four Residents (#40, #89, #57 and #22) out of a total sample of 19 residents. Specifically, for Resident #40, #89, #57 and #22, the facility failed to ensure that: -quarterly care plan meetings were conducted as required -the Resident/Resident Representative were invited to participate in the care planning process. -the Interdisciplinary Team (IDT) met quarterly in 2024 to review the plan of care as required. Findings include: Review of the facility policy titled Care Planning-Interdisciplinary Team (IDT), undated, included the following: -the IDT include but is not limited to: <the resident's attending physician; <registered nurse with responsibility for the resident; <nursing assistant with responsibility for the resident; <a member of the food and nutrition services staff; <the resident or the resident's representative. -the resident, the resident's family and or legal representative . are encouraged to participate in the development of and revisions to the resident's care plan. -care plan meetings are held at the best time of the day for the resident and family when possible. -if it is determined that participation of the resident or representative is not practicable for the development of the care plan, an explanation is documented in the medical record. Review of the facility policy for Care Plans- Comprehensive, last revised July 2023, indicated: -the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .at least quarterly. -the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. 1. Resident #40 was admitted to the facility in February 2024 with diagnoses including Adjustment Disorder and Dementia. Review of the Resident's most recent Minimum Data Set (MDS) assessment completed 11/21/24 indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 points. Review of Resident #40's clinical record included MDS assessments completed on 5/24/24 and 9/3/24. Further review of the Resident's record indicated no documented evidence Resident #40's care plan was reviewed by the IDT to include the Resident and/or a Resident Representative following the completion of the May 2024 and September 2024 MDS assessments. During an interview on 1/21/25 at 10:42 A.M., the MDS Nurse said the facility could provide no evidence any care plan meetings involving the Resident/ Resident Representative were held for the May 2024 or September 2024 MDS assessments. The MDS Nurse said the care plan meetings should have been held. 2. Resident #89 was admitted to the facility in August 2024 with diagnoses including Malignant Neoplasm of the Prostate, Dementia with Mild Anxiety and Adult Failure to Thrive. Review of the Resident's most recent MDS completed on 11/7/24 indicated the Resident was moderately cognitively impaired as evidenced by a BIMS score of 8 out of 15. Review of the clinical record indicated no documented evidence that Resident #89's care plan was reviewed by the IDT to include the input of the Resident and/or their Representative for the MDS assessment completed on 11/7/24. During an interview on 1/16/25 at 9:43 A.M., the Director of Nursing (DON) provided the surveyor with the facility's November 2024 care plan meeting schedule which included the Resident's name but no other information regarding completion of an IDT care plan meeting. The DON said she could not provide any evidence a care plan meeting was held that involved the Resident and/or a Resident Representative. 44222 3. Resident #57 was admitted to the facility in February 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Major Depressive Disorder, and Unspecified Psychosis. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], included a BIMS score of 10 out of 15 points indicating the Resident was moderately cognitively impaired. Review of the clinical record indicated no evidence that the Resident and/or their Representative were invited to, or that a care plan meeting was held after completion of the MDS Assessment. During an interview on 1/13/25 at 10:49 A.M., Resident #57 said that he/she never goes to care plan meetings. During an interview on 1/16/25 at 9:38 A.M., the DON said the facility could provide no evidence a care plan meeting involving the Resident and/or their Representative was held following the 8/20/24 MDS assessment. The DON said the Resident and/or their Representative should have been invited to, and a care plan meeting held after completion of the MDS Assessment on 8/20/24 but it had not been. 45429 4. Resident #22 was admitted to the facility in September 2022 with diagnoses including Malignant Neoplasm of the Brain (brain cancer) and Multiple Sclerosis. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #22 was cognitively impaired as evidenced by a BIMS score of 3 out of 15. Review of the MDS schedule for Resident #22 indicated that the Resident had care plan meetings scheduled for April 2024 and July 2024. Review of Resident #22's clinical record indicated no documented evidence that the Resident and/or the Resident Representative participated in the care planning process or that the IDT met quarterly as required for April 2024 or July 2024, to review the plan of care. Further review of the clinical record indicated there were no meetings or refusals to participate in the meetings by the Resident and/or the Resident Representative documented for April 2024 or July 2024. During an interview on 1/13/25 at 12:03 P.M., Resident #22's invoked (activated) Health Care Proxy (HCP- a legal document that allows you to nominate someone to make health care decisions on your behalf should you become unable to communicate or make decisions for yourself) said that he/she had not been invited to attend or involved in care plans meetings at the facility. During an interview on 1/16/25 at 12:01 P.M., the MDS Nurse and the Regional MDS Nurse said that they were unable to provide evidence that Resident #22 or their Resident Representative had been invited to or participated in the care plan meetings in April 2024 or July 2024. The MDS Nurse and the Regional MDS Nurse said that the Resident and/or the Resident Representative should have been invited, the meetings should have been held, and they had not been.

Based on observation, and interview, the facility failed to post the required nurse staffing information daily as required. Specifically, the facility failed to: -post daily nurse staffing information in a prominent place, that was readily accessible to facility residents and visitors. -retain a copy of staffing records for 18 months as required. Findings include: During the facility recertification survey the surveyor observed no daily nursing staff information posted on the following days: -1/13/25 -1/14/25 -1/15/25 During an interview on 1/15/25 at 9:27 A.M., the Administrator said he knew the nurse staffing information should be posted in a prominent area, and he would find out where it was posted. The Administrator failed to provide evidence to the survey team by the survey exit of the nursing staff posting information for 1/13/25, 1/14/25, and 1/15/25. During an interview on 1/16/25 at 1:55 P.M., the [NAME] President (VP) of Operations said he knew staffing should be posted daily in a prominent place. The VP of Operations showed the surveyor the nurse staffing information was posted at the front desk for the date of 1/16/25 and said that was where it should be posted daily. The VP of Operations also said he did not have 18 months of daily nurse staff postings maintained in the facility records as required.

Based on observation, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent foodborne illness to residents. Specifically, the facility failed to: 1. Discard spoiled food and food that was past the use by date, and label and date prepared food. 2. Distribute and serve food in the main dining room under sanitary conditions. Findings include: 1. Review of the facility policy and procedure manual Chapter 3: Food Production and Food Safety, undated, indicated: -Refrigerated food storage, all foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates or frozen (where applicable) or discarded. -All stock must be rotated with each new order received. -Foods should be dated as it is placed on the shelves if required by state regulations. -Date marking will be visible on all high-risk foods to indicate the date by which ready to eat, temperature-controlled food should be consumed, sold, or discarded. Review of the Live Well Healthcare Solutions Policy on Food Storage, undated, provided to the surveyor by the Corporate Food Service Director indicated: -All foods will be held according to manufacturer's guidelines and expiration dates. -All foods not labeled with an expiration date will be discarded according to guidelines outlined in the policy. -All foods will be labeled with a use by date when opened and stored in an appropriate manner. -Fresh fruit or vegetables - whole, should be in the refrigerator stored 37-40 degrees Fahrenheit for one week or until visual decline is noted. During the initial tour of the facility kitchen on 1/13/25 at 7:27 A.M., the surveyor observed the following: -In the walk-in refrigerator: >cucumbers that were individually wrapped and sealed in plastic and stored in a cardboard box with a packed-on date of 12/18/24. The cucumbers had a white moldy film on them under the plastic wrap. >Sandwiches that were individually wrapped and stacked in a container on the second shelf from the top and were undated and unlabeled. -In the reach-in refrigerator: >stored on the bottom shelf in a metal container was a tube of ground beef labeled with a use by date of 1/9/25. During an interview on 1/13/25 at 7:45 A.M., Dietary Staff #1 said both the cucumbers and the ground beef should have been thrown away and not used. Dietary Staff #1 said the sandwiches should have been dated before they were put in the refrigerator. During an interview on 1/15/25 at 12:08 P.M., the Corporate Food Service Director (FSD) said the ground beef seen on the initial kitchen tour with a use by date of 1/9/25 was mislabeled and was pulled from the freezer to thaw on 1/9/25, to use for service on 1/13/25. The Corporate FSD said he was not there the morning of the initial kitchen walk through and did not see the only label that the surveyor observed to have a use by date of 1/9/25. The Corporate FSD said the ground beef should have been labeled with a pull and preparation date as well as a use by date. The Corporate FSD said if the cucumbers were moldy, they should have been thrown away and not used. The Corporate FSD further said the sandwiches or the container they were stored in should have been labeled and dated. The Corporate FSD said the staff have a guide for food storage attached to the walk-in refrigerator which tells them how to properly store and discard food and they should have been following those guidelines. 2. Review of the facility policy Assistance with Meals, version 2.0, undated, indicated all employees who provide resident assistance with meals will be trained and shall demonstrate competency in prevention of foodborne illness, including personal hygiene practices and safe food handling. During a dining observation on 1/16/25 at 11:50 A.M., in the main dining room the surveyor observed the following: -a drink station including coffee, pitchers of juices and sealed juice cups stored in a metal container on top of ice, and trays with clean cups and mugs alongside the drinks. -drinks being served to the residents from the drink station by nursing staff. -A tray on the same drink station was storing dirty cups, dirty silverware, and dirty pitchers. Staff were observed taking used cups from the Resident's tables and placing them on the tray next to the tray with clean items. -Activities Assistant (AA) #1 was observed getting a clean cup from the drink station and with ungloved hands used the clean cup to scoop contaminated ice from the metal container housing the drink pitchers and juice cups. AA #1 poured the ice into a resident's cup on the table and handed the cup to the resident. The Director of Nursing (DON) intervened and stopped the resident from drinking from the contaminated cup. The DON educated AA #1 that she could not use ice from the container that the drinks were stored in. The contaminated ice and the cup were taken from the resident and a clean cup with ice was provided to the resident. -At 12:06 P.M., the tray with the dirty cups and utensils on the drink station had been removed and several staff members were observed leaving dirty cups and utensils directly on the table with the clean drinks and cups. During an interview on 1/16/25 at 12:26 P.M., the Corporate FSD said there should not have been dirty items on the same table with the clean items at the drink station. The Corporate FSD said staff should not have been using the dirty ice from the drink station to serve to the residents. The Corporate FSD said staff should be using the clean ice provided in pitchers on the table. During an interview on 1/16/25 at 4:20 P.M., the DON said the staff member should not have used the dirty ice for resident drinks. The DON said the dirty cups and utensils should be put in a separate container and not on the drink station with the clean cups and drinks being served to the residents. The DON said all the staff should be trained on food safety and infection control if they are assisting with dining program. The DON said she was unsure if AA #1 had been educated on safe food handling.

Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#7) out of a total sample size of 19 residents. Specifically, the facility failed to maintain the Resident's enteral feeding pump pole in a clean and sanitary manner when the base of the pole stand was visibly soiled with spilled substances. Findings include: Review of the facility's policy titled Resident Care Equipment Processing Between Resident Use and Transport, undated, indicated the following: -The employee will wear appropriate personal protective equipment when handling, cleaning or transporting soiled material. -Enteral feeding poles will be cleaned if visibly soiled and routinely. -Each department will determine accountability within their area. Resident #7 was admitted to the facility in February 2017 with diagnoses including Dysphagia and Gastrostomy Status. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #7: -had severely impaired cognitive skills for daily decision making. -rarely understood others or was understood by others. Review of Resident #7's medical record included but was not limited to the following: -A Physician's order for enteral feeding (also referred to as G-tube feeding) of Jevity 1.5 at 30 ml/hr (milliliters per hour) continuous, effective 11/4/24. Review of the Comprehensive Person-Centered Care Plan for Nutritional Concerns included but was not limited to: -Nutritional Concerns related to chewing and swallowing difficulty with interventions including but not limited to a need for enteral feeding, effective 12/23/20. On 1/13/25 at 8:32 A.M., the surveyor observed Resident #7 lying in bed with enteral feeding running as ordered from a pump that was connected to a pole. The surveyor also observed a large quantity of dried, milky colored substance covering the base of the enteral pole stand. On 1/14/25 at 7:30 A.M., the surveyor observed Resident #7 lying in bed, with enteral feeding running as ordered from a pump that was connected to a pole. The surveyor observed that a large quantity of dried, milky colored substance remained covering the base of the enteral pole stand. On 1/15/25 at 10:41 A.M., the surveyor observed Resident #7 lying in bed, with enteral feeding running from a pump as ordered, and the base of the enteral pole stand remained covered with a large quantity of dried, milky colored substance. During an observation and interview on 1/15/25 at 10:52 A.M., the surveyor and Certified Nurses Aide #1 (CNA #1) observed the Resident's enteral feeding pole. CNA #1 said that the base of the pole was dirty and should have been cleaned up when the spills were made. CNA #1 said that she was assigned to Resident #7 at the time. CNA #1 said the housekeeping department never cleans the enteral pumps or poles. CNA #1 said that the nursing staff who spilled the liquid should have wiped the enteral feeding pole off as soon as it happened because the staff have wipes that could be used on the enteral pump pole. CNA #1 said that she could have also cleaned the dirty enteral pump pole. On 1/15/25 at 11:02 A.M., the surveyor and the Assistant Director of Nurses (ADON) observed the enteral feeding pole and the ADON said the pole was dirty. The ADON said that housekeeping and nursing were responsible to maintain cleanliness on the unit. The ADON said that spills should be wiped up immediately to prevent attraction of pests and to maintain a proper environment because nobody would want to have dirty things in their home.

Based on record review, and interview, the facility failed to ensure prompt efforts to resolve a grievance for one Resident (#84) out of a total sample size of 19 residents. Specifically, for Resident #84, the facility failed to investigate and resolve a grievance for missing personal property when the Resident's electronic communication tablet that was used to communicate with staff was reported missing. Findings Include: Review of the facility policy titled, Administration: Grievance Policy, revised November 2016, indicated the following: -The facility will support the resident/responsible party to voice grievances/concerns regarding .lost articles or any violation of resident's rights. -Upon receipt of the grievance/concern the facility will take appropriate measures to seek a resolution to the concern. -The Administrator will appoint a Grievance Officer. -The Grievance Officer will be responsible to ensure that all grievances are responded to in a timely manner. -Facility staff is encouraged to attempt to resolve the verbal grievance/concern at the time it is brought forward whenever possible. In the case that the grievance/concern cannot be resolved promptly, the staff member will complete the grievance form or give it to the person with the concern to complete. -Once the form is complete it will be forwarded to the Social Service Department. -During the absence of the social worker, the forms will be forwarded to the Administrator. The grievance/concern book will be kept in the Administrators office. -The Social Worker will review the grievance/concern and forward a copy to the appropriate department head. The Social worker will keep the original and document the receipt of the grievance/concern form on the grievance log. -The Department head is responsible for investigating the concern and developing a plan to resolve it. -The Administrator is responsible for reviewing grievances/concerns weekly to ensure that they have been investigated and resolved to the residents/responsible party satisfaction. Resident #84 was admitted to the facility in February 2024 with diagnoses including Aphasia, Hemiplegia and Hemiparesis following Nontraumatic Intracerebral Hemorrhage affecting right dominant side, and Major Depressive Disorder. Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -Resident had no speech (absence of spoken words) -Resident was sometimes understood (ability limited to making concrete requests) -Resident was able to understand others usually (misses some part/intent of message but comprehends most conversation responds adequately to simple, direct communication only). -A Brief Interview for Mental Status (BIMS) assessment had not been attempted. Review of Resident #84's complete medical record indicated: >A Legal Guardianship was established on 7/10/24. Review of Resident #84's Care Plan for Communication, created on 5/22/24 and last revised on 5/22/24, indicated: >Resident #84 had a communication problem related to Aphasia. >Goal was for the Resident to maintain a current level of communication by using a communication device, gestures, pointing, responding to yes/no questions as indicated/need. >Interventions included to use alternative communication tools as needed. Review of the Speech Therapy Discharge Summary dated 9/6/24, indicated: -Resident and caregivers were to utilize compensatory strategies to repair communication breakdown (cues, gestures and ACC (Augmentative and Alternative Communication- a communication device tablet) system. -Interventions included: >modification of the Resident's ACC communication device. >addition of functional icons and included addition of home exercises to patient's AAC device for both practice and communication. >modification of patient's AAC device were made to place more frequently used icons in easier to access locations. Review of the Nursing Progress Note dated 11/30/24 at 9:02 A.M. indicated: -client trying to communicate. Nursing staff explained to this Nurse that pt's (patient's/ Resident) tablet is missing. -Also, client refusing medications today and wants to leave that room. Supervisor notified. Review of the Nursing Progress Note dated 11/30/24 at 1:50 P.M. indicated: -client, I've been told, has a tablet to communicate. The tablet hasn't been found. -PT (Physical Therapy) looked in rehab. -I searched pt. room. I did not locate the tablet and how many days it's been missing, this Nurse does not know. During an interview on 1/15/25 at 2:38 P.M., Certified Nurses Aide (CNA) #2 said that Resident #84 had an electronic communication tablet that was used to talk to the staff. CNA #2 said that the communication tablet had pictures on the screen that the Resident could point at to make his/her needs known. CNA #2 said that he had not seen the communication tablet in a long time so it must be missing. CNA #2 said that he had not communicated the missing communication tablet to anyone because he was pretty sure they all knew it was missing a few months ago. During an interview on 1/15/25 at 2:41 P.M., the Administrator said that he was the Grievance Officer in the facility and keeps the grievance binder in his office. The Administrator said that he was unaware that the communication device belonging to Resident #84 had been missing and did not have a grievance form related to the missing communication tablet. During an interview on 1/15/25 at 3:01 P.M., the Speech Therapist (ST) said the ACC tablet had been purchased though the Resident's insurance and therefore was Resident #84's personal property. The ST said the ACC tablet, in addition to hand gestures as well as yes and no questions, was a communication method used by Resident #84 to make his/her needs known. The ST said that she was aware that the communication tablet had been missing but the tablet was not removed from the Care Plan for Communication at any time nor was she asked to perform an evaluation once the communication device was no longer available for the Resident to use. During an interview and record review on 1/21/25 at 8:51 A.M., the Assistant Director of Nurses (ADON) said she had located the original grievance form which had been completed by the Supervising Nurse on 11/30/24. Review of the Grievance Form dated 11/30/24, provided by the ADON indicated: -Tablet of Resident #84 used for communication was missing and the Guardian had been notified by the nursing supervisor. -Evidence of an action taken to resolve grievance was blank (on the form). -Evidence of person responsible for resolution was blank. -Evidence of follow-up on completion was blank. -Social Worker signature and date were blank. -Administrator signature and date were blank. The ADON said that the grievance form dated 11/30/24, had been located in the Contracted Social Worker's binder, but the Contracted Social Worker was no longer in the facility. The ADON said that she was able to recall that the missing AAC tablet had been discussed at the morning staff meeting a few times but was unsure what happened thereafter. The ADON said the grievance process should have been addressed sooner but had not been.

Based on observation, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to dental status for Resident #79. Findings include: Resident #79 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol. Review of the most recent MDS Assessment completed on 11/8/24, indicated that the Resident: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 possible points. -had no obvious or likely cavity or broken natural teeth, no difficulty noted to examine the Resident's teeth. On 1/13/25 at 11:03 A.M., the surveyor observed that Resident #79 had no teeth on the top gum line, and had three teeth on the bottom gum line, two of which were dark in color and broken. On 1/21/25 at 9:23 A.M., the surveyor and the Director of Nursing (DON) observed the Resident's teeth and observed no teeth on the top gum, and three teeth on the bottom gum, two of which were dark in color and broken. During an interview at the time, the Resident said my other teeth are at home. During an interview on 1/21/25 at 9:35 A.M., with the DON and the MDS Nurse, the DON said that the most recent comprehensive MDS assessment completed on 11/8/24 was completed by an off-site MDS Nurse and she could not provide evidence that any staff member or the MDS Nurse completing the MDS actually examined the Resident's mouth for dental status. The DON said the MDS coding for the Resident's dental status was inaccurate. The MDS Nurse said that the MDS responses for dental status came from the previous MDS assessment completed on 11/13/23, and were just kept the same for the MDS assessment completed on 11/8/24. Please Refer to F791

Based on observation, interview, and record review, the facility failed to provide assistance with personal hygiene care and services for two Residents (#15 and #57) out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Resident #15 was offered and/or provided with grooming assistance for fingernail care and facial hair care when the Resident was dependent on staff for both grooming tasks. 2. Resident #57 was offered and/or provided grooming assistance for fingernail care when the Resident was dependent on staff for this task. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, undated, included: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 1. Resident #15 was admitted to the facility in February 2015 with diagnoses including Unspecified Dementia, Major Depressive Disorder, Dysphagia following Unspecified Cerebrovascular Disease, Type 2 Diabetes, and Atherosclerotic Heart Disease. Review of Resident #15's ADL Care Plan last revised 11/6/24, indicated that the Resident was dependent on one staff for all personal hygiene tasks, including fingernail care and facial hair care. Review of the Resident's most recently completed Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was severely cognitively impaired. -Brief Interview for Mental Status (BIMS) assessment was not done. -was dependent on staff for personal hygiene tasks including fingernail care and facial hair care. -had no rejection of care noted on the MDS Assessment. 0n 1/13/25 at 11:32 A.M., the surveyor observed Resident #15 to have long facial hair on the chin, and fingernails that were long with debris under the fingernails. The Resident was dressed for the day and had received morning care. On 1/14/25 at 11:40 A.M., the surveyor observed the Resident in the main dining room. The Resident's fingernails were observed to be long with debris under the fingernails, and the Resident had long facial hair on the chin. The Resident was dressed for the day and morning care had been provided. Review of Resident #15's clinical record did not indicate any refusals by the Resident during grooming care provided by staff. Review of the Resident's Certified Nurses Aides (CNA) Daily Care Record indicated that the CNA provided total care for Resident #15's personal hygiene care on 1/13/25 for both morning and evening care, and again on 1/14/25 for morning care. During an observation and interview on 1/14/25 at 11:45 A.M., the surveyor and the Director of Nursing (DON) observed Resident #15's fingernails and facial hair. The DON said that the Resident's fingernails should have been trimmed but had not been, and the Resident's facial hair should have been removed but had not been. The DON said that fingernail care and care for facial hair was part of the grooming task and the Resident's fingernails and facial hair should have been checked and cared for as needed during morning and evening care. During an interview on 1/16/25 at 2:50 P.M., CNA #5 confirmed that the Resident was on his assignment on 1/14/25. CNA #5 said that the Resident was totally dependent on staff for care. He said that he was working with another CNA and did not notice the Resident's fingernails or facial hair. CNA #5 said he did not provide any nail care or facial shaving care to the Resident on the morning of 1/14/25. CNA #5 said that on the afternoon of 1/14/25 the DON requested that he check the Resident's fingernails and facial hair. CNA #5 said that he found the Resident's fingernails long and dirty and the hair on the Resident's chin was long. CNA #5 said that the Resident's nails should have been trimmed/cleaned and the facial hair removed during morning care on 1/14/24 but they had not been. 2. Resident #57 was admitted to the facility in February 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Major Depression, and unspecified Psychosis. Review of the Resident's most recently completed MDS assessment dated [DATE], indicated the Resident: -was moderately cognitively impaired as evidenced by a score of 10 out of 15 points on the Brief Interview for Mental Status (BIMS) assessment, -was dependent on staff for personal hygiene tasks including fingernail care. -had no rejection of care noted on the MDS Assessment. Review of Resident #57's care plan last revised 11/19/24 indicated that the Resident required the assistance of one staff for personal hygiene with encouragement to participate in the task to his/her fullest ability. On 1/13/25 at 10:51 A.M., the surveyor observed Resident #57's fingernails to be long and jagged. During an interview at the time, the Resident said he/she needed the fingernails to be trimmed. On 1/14/25 at 9:52 A.M., the surveyor observed Resident #57's fingernails to be long and jagged. The Resident was dressed for the day and morning care had been completed. Review of Resident #57's clinical record did not indicate any refusals by the Resident during grooming care provided by staff. Review of the Resident's Certified Nurses Aide (CNA) Daily Care Record indicated that the CNA provided total care for Resident #57's personal hygiene care on 1/13/25 for both morning and evening care, and again on 1/14/25 for morning care. During an observation and interview on 1/14/25 at 11:45 A.M., the surveyor and the DON observed Resident #57's fingernails and the DON said that the Resident's nails should have been trimmed but had not been. The DON said that fingernail care was part of the grooming task and the Resident's fingernails should be checked and cared for as needed during morning and evening care. During an interview on 1/16/25 at 2:40 P.M., CNA #4 said that she had provided care for Resident #57 on the morning of 1/14/25. CNA #4 said that morning care does include fingernail care but she said that she was rushing and didn't recall seeing that the Resident's fingernails were long and jagged. CNA #4 said that she reviewed the Resident's fingernails later that afternoon on 1/14/25 and provided needed fingernail care. CNA #4 said that the Resident's nails were long and jagged and she should have trimmed the fingernails that morning but had not done so.

Based on observation, record review, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#252) out of a total sample of 19 residents, who required renal dialysis. Specifically, the facility failed to ensure that an emergency kit including clamps and pressure dressings were kept with the Resident (#252) and the Resident's bedside as ordered, in the event of a medical emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: Review of the facility policy for End-Stage Renal Disease (ESRD), Care of a Resident with, undated, indicated: -staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes specifically: < .how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; <how to recognize and manage equipment failure or complications (according to the type of equipment used in the facility; <the care of grafts (piece of plastic inserted to connect a vein and an artery; second choice for access) and fistulas (connection between a vein and an artery; generally last longer and has fewer problems); -the residents comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Resident #252 was admitted to facility in January 2025 with diagnoses including Chronic Kidney Disease (CKD) Stage 5, and dependence on renal dialysis. On 1/13/25 at 12:22 P.M., the surveyor observed Resident #252 resting in bed with his/her family sitting at his/her bedside. During an interview at the time the Resident's family said that Resident #252 had a central venous catheter located in his/her chest. The surveyor and the Resident's family member observed the Resident's room and did not observe any clamps and pressure dressings at the Resident's bedside or in the Resident's room. Review of Resident #252 Physician's orders for January 2025 indicated: -Hemodialysis Emergency Kit at Bedside, start date of 1/5/25 -Monitor Hemodialysis site for signs and symptoms of infection, every shift for dialysis, start date of 1/5/25 -Resident going to dialysis every Saturday, Tuesday, Thursday, at Dialysis Clinic out of the facility, start date of 1/3/25 On 1/14/24 at 7:57 A.M., the surveyor and Nurse #2 observed the Resident resting in bed in his/her room. There was no emergency kit including clamps and pressure dressings observed at the Resident's bedside or in the Resident's room. The surveyor and Nurse #2 observed the inside of Nurse #2's medication cart and there were no clamps available in the cart as well. During an interview on 1/14/25 at 8:28 A.M., Nurse #2 said that if there was an emergency she would utilize a tourniquet (device used to place pressure on a limb or extremity to stop the flow of blood) on the Resident's arm. When the surveyor asked if Nurse #2 was familiar with the Resident's care, Nurse #2 said that she was not aware that the venous catheter access site was not located on the Resident's arm. During an interview on 1/14/25 at 9:26 A.M., the Director of Nursing (DON) said that the clamp should have been at the Resident's bedside, and they were not. The DON also said that facility staff had used the clamp for another resident's wound care and the clamp had not been put back in its place.

Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) was acted upon as required for one Resident (#20), of five applicable residents reviewed for unnecessary medications, out of a total sample of 19 residents. Specifically, the facility failed to act upon the Consultant Pharmacist recommendation dated 3/18/24, to update the Physician's order for Budesonide (inhaled steroid medication) to instruct the Resident to rinse mouth after use to prevent the development of oral thrush, after it had been approved by the Resident's Physician. Findings include: Review of the facility policy for Consultants, undated, indicated: -our facility uses outside resources to furnish specific services provided by the facility -consultant services may be utilized in the following areas: Pharmacy -consultants provide the Administrator with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's: <recommendations <plans for implementation of his/her or recommendations <findings and <plans for continued assessments -the facility retains the professional and administrative responsibility for all services provided by consultants. Resident #20 was admitted to the facility in September 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #20's Physician's orders indicated: -Budesonide Inhalation Suspension 0.5 Milligrams (MG)/2 Milliliters (ML) Budesonide (Inhalation), one inhalation, inhale orally two times a day for COPD, start date of 10/31/24. Review of Resident #20's Clinical Record indicated a Consultant Pharmacist Recommendation to Nursing dated 3/7/24 that indicated: -Resident is receiving Budesonide. In order to prevent the development of thrush please update order to instruct Resident to rinse mouth after use. -that the Recommendation had been reviewed and agreed to by the Physician. Further review of the Clinical Record did not indicate that the Consultant Pharmacist Recommendations had been added to the Physician's orders as suggested. During an interview on 1/16/25 at 9:34 A.M., the surveyor and the Director of Nursing (DON) reviewed the Consultant Pharmacist Recommendation to Nursing dated 3/7/24 as well as Resident #20's clinical record. The DON said that the recommendation should have been added to the Resident's Physician's orders in order to prevent thrush development but it had not been.

Based on observation, record review, and interview, the facility failed to ensure that drugs were stored in accordance with accepted professional standards of practice for a medication pass process for Resident #20 out of four medication passes observed. Specifically, the facility nursing staff failed to ensure that medications prepared for Resident #20 were secure and inaccessible to unauthorized staff and residents when Nurse #1 left the prepared medications on the top of the cart, left the cart unattended and unlocked in the hallway outside the Resident's room on multiple occasions, while administering the medications to the Resident in his/her room. Findings include: Review of the facility's policy titled Storage of Medications, last revised April 2007, indicated the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including but not limited to drawers .carts and boxes) containing drugs and biologicals shall be locked when not in use . or carts used to transport such items shall not be left unattended if open or potentially available to others. On 1/15/25 at 8:49 A.M., the surveyor observed Nurse #1 complete the following tasks during medication pass for Resident #20: -Medications were prepared by Nurse #1 on top of the medication cart in the hallway, just outside the doorway of Resident #20's bedroom. -Medications prepared included two cups of oral (taken by mouth) medications, one nasal (taken by way of nostrils) spray, and one single dose ampule of inhalation (taken by breathing in) medication. -Nurse #1 then entered Resident #20's room leaving the medication cart in the hallway, unattended and unlocked with the nasal spray, the inhalation medication, and one cup of oral medication on top of the cart. There were two residents, one facility staff member, and the surveyor in the hallway in close proximity of the medication cart when Nurse #1 entered the Resident's room. -Nurse #1 returned to the medication cart and collected the single dose ampule inhalation medication from the top of the medication cart and left the unlocked medication cart with the cup of oral medication and nasal spray on top of the cart in the hallway and re-entered Resident #20's bedroom. -Nurse #1 was observed to walk behind Resident #20's privacy curtain and obstructing her view of the medication cart as she collected a nebulizer (electric pump that delivers inhaled medication in an aerosol form). Nurse #1 was further observed with her back to the medication cart which remained in the hallway, as she proceeded to fill the nebulizer with the inhaled medication and left the filled nebulizer container at the Resident's bedside. -Nurse #1 returned to the medication cart in the hallway, collected the nasal spray, and re-entered Resident #20's bedroom leaving the medication cart unlocked and one cup of oral medication on top of the cart. Nurse #1 had the medication cart out of view when she turned her back to the cart to administer the nasal spray to Resident #20. -Nurse #1 then returned to the medication cart. During an interview at the time, the surveyor asked Nurse #1 if leaving the medication cart unlocked and unattended during medication administration was standard practice, Nurse #1 said she always leaves the medication cart unlocked during medication pass so that she didn't have to mess around with all the keys. Nurse #1 said she thought it was easier not to have to find the key every time she returned to the medication cart. -Nurse #1 was observed to walk away from the unlocked, unattended medication cart in the hallway, and one cup of oral medication remained on top of the medication cart. -Nurse #1 re-entered the Resident's bedroom, repositioned Resident #20 in bed, and then administered the inhaled medication from the nebulizer. During an interview on 1/15/25 at 9:04 A.M., the Director of Nursing (DON) said she had concerns with medication carts being left unlocked while unattended during medication pass due to safety for other residents on the unit. The DON said medications should be secured and medication carts locked when not in use or unattended.

Based on observation, interview, and record review, the facility failed to ensure that dental services were provided for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to provide dental services for Resident #79 after the Resident's Guardian requested dental services. Findings include: Review of the facility policy titled Dental Services, undated, included: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and 24-hour emergency dental services are provided to our resident's through a contract agreement with a licensed dentist that comes to the facility. Resident #79 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol. Review of the Resident's Care Plan did not include any problems, goals, or interventions for dental care. Review of the Dental Services Contract indicated that the Resident's Guardian requested dental services on 7/18/24. Review of the most recent Minimum Data Set (MDS) Assessment completed on 11/8/24, indicated the Resident: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 possible points. -had no obvious or likely cavity or broken natural teeth -displayed no difficulty to examine his/her teeth. On 1/13/25 at 11:03 A.M., the surveyor observed the Resident's teeth that there were no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. During an interview on 1/21/25 at 7:41 A.M., the Director of Nursing (DON) reviewed the Resident's record and said she could not find any evidence that the Resident had been offered dental services. During an interview on 1/21/25 at 8:19 A.M., the DON said that when a resident or a resident representative signs a request for dental services, the resident was then put on a list to be seen by the dental services vendor. The DON said that the Resident #79 was never referred to the dental services vendor but should have been. On 1/21/25 at 9:23 A.M., the surveyor and the DON observed the Resident's teeth and saw there were no teeth on the top gum line, there were three teeth on the bottom gum line, two of which were dark in color and broken. During an interview at the time, the Resident said my other teeth are at home and it's good that my teeth don't hurt. The DON said that the Resident should have been referred for dental services as requested, but had not been. The DON further said that the on-site dental service had been at the facility multiple times since July 2024 but the Resident had not been seen.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#12) who had tested positive for COVID-19, out of a total sample of 19 residents. Specifically for Resident #12, the facility failed to ensure that staff: -wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. to prevent transmission of communicable disease) to maintain isolation contact/droplet precautions (used to prevent transmission of a disease spread by touching a contaminated surface or person). -performed hand hygiene procedure after removing gloves as required. Findings include: Resident #12 was admitted to the facility in April 2004 with diagnoses including Paranoid Schizophrenia. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, undated, indicated the following: -Contact Precautions <Staff and visitors will wear gloves (clean, non-sterile) when entering the room <gloves will be removed and hand hygiene performed before leaving the room -Droplet Precautions <masks will be worn when entering the room <gloves, gown and goggles will be worn if there is risk of spraying respiratory secretions Review of the facility policy for Coronavirus Prevention and Control, last revised May 2023, indicated: -The administrator or designee will ensure the following are available at the facility: .<PPE (gloves, gowns, eyewear, facemasks) -Contact and droplet precautions are implemented for any residents with symptoms of respiratory infection and standard precautions will be used as indicated. Review of Resident #12's January 2025 Physician's orders indicated: -COVID Isolation - Contact Precautions in private room due to positive for COVID, start date of 1/11/25. Review of Resident #12's Care Plan for confirmed COVID-19 dated 1/11/25, indicated: -Isolation Precautions -Contact/Droplet Precautions On 1/13/25 at 9:45 A.M., the surveyor observed: -Isolation/Droplet/Contact Precaution signage posted outside of Resident #12's room which indicated: >for Everyone: -to cleanse hands before entering and when exiting the room. -wear gloves, a gown, N95 Respirator, Eye Protection (face shield or goggles) -use patient dedicated or disposable equipment. -clean and disinfect shared equipment -the PPE bin outside Resident's #12's room did not include goggles or face shields. On 1/13/25 at 11:37 A.M., the surveyor observed Housekeeper #1 enter Resident #12's room with Isolation/Droplet/Contact Precaution signage posted outside the door. Housekeeper #1 was observed to: -don all the PPE indicated on the Precaution sign except for goggles/eyewear. -enter the room and clean all the surfaces. -exit the room and doff all PPE in receptacle. -not perform hand hygiene after doffing her gloves and donning new gloves and proceeding to clean another room. During an observation on 1/14/25 at 8:06 A.M., the surveyor observed CNA #3 enter Resident #12's room with a breakfast tray. CNA #3 was observed to: -don all the PPE indicated on the Precaution sign except for goggles/eyewear. -Provide Resident #12 with his/her breakfast tray in the room, exit the room and doffed his PPE. During an interview on 1/14/25 at 8:10 A.M., CNA #3 said that he did not wear goggles or eye protection when entering Resident #12's room because they were not available. When the surveyor opened the PPE bin to find there were goggles available and showed them to CNA #3, CNA #3 said that he should have worn eye protection. CNA #3 said that the facility had recently given an in-service on PPE use so he knew that he should have worn eye protection prior to entering Resident #12's room and he did not. During an interview on 1/14/25 at 2:39 P.M., the Director of Nursing (DON) said that both Housekeeper #1 and CNA #3 should have worn eye protection before entering the COVID-19 positive room. The DON also said that Housekeeper #1 should have performed hand hygiene after taking off her potentially soiled gloves and putting on another pair of gloves.

Based on record review, and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for two Residents (#57 and #58), out of a total sample of 19 residents. Specifically, the facility failed to: 1. for Resident #57, accurately complete a Level I PASRR when the Resident's admission PASRR indicated no SMI, and the Resident was admitted to the facility with SMI diagnoses and a recent hospitalization where psychiatric services were provided resulting in a Level II PASRR Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services) not being completed as required. 2. for Resident #58, the facility failed to accurately complete a Level I PASRR indicating that the Resident had received psychiatric services while hospitalized within the last two years in the community, resulting in a Level II PASRR Evaluation not being completed as required. Findings include: Review of the facility policy titled Preadmission Screening and Resident Review (PASSR), effective 4/18, included: -It is the policy to screen all potential admissions on an individual basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) .for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder. -The facility will report any changes as identified via the screen to the state mental health authority . -The PASARR will be evaluated annually and upon any significant change for those individuals identified. 1. Resident #57 was admitted to the facility in February 2024 with diagnoses including Major Depressive Disorder Recurrent Unspecified, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, Post Traumatic Stress Disorder (PTSD), and Anxiety. Review of the PASRR Level I Screening dated 2/13/24, indicated that the Resident had no Serious Mental Illnesses (SMI). Review of the Resident's Facility Admission Record indicated the following diagnoses were present upon admission: -Unspecified Psychosis Not Due to a Substance or Known Physiological Condition -Major Depressive Disorder Recurrent Unspecified -Post Traumatic Stress Disorder (PTSD) Review of the Physician Admission Note dated 2/17/24 included: -The patient with multiple medical issues who was hospitalized with confusion and agitation and mental status changes. -now admitted to the .rehab center for skilled nursing rehab and psychiatry evaluation and management -past medical history includes depression, anxiety, insomnia, psychosis . -Olanzapine (anti-psychotic medication) 5 milligrams (mg) for psychosis is in place. -Depression is treated with Cymbalta (anti-depressant medication) extended release 30 mg a day, and we will follow. Review of the Psychiatric Evaluation and Consultation dated 2/19/24 included: -Post Traumatic Stress Disorder (PTSD) - chronic illness -Anxiety Disorder - chronic illness Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE], included a diagnosis of Post Traumatic Stress Disorder. Review of the Resident's MDS dated [DATE], included diagnoses of: -Psychotic Disorder -Anxiety -Depression -Post Traumatic Stress Disorder (PTSD) During an interview on 1/21/25 at 11:05 A.M., with the MDS Nurse and the Director of Nursing (DON), the MDS Nurse said that she had added the psychiatric diagnoses to the Resident's clinical record and MDS when she identified them in the hospital and provider notes from the Resident's admission to the facility. The MDS Nurse said that all of the psychiatric/mood diagnoses listed on the Resident's MDS Assessment were from the Resident's records before or on admission to the facility. The DON reviewed the admission PASRR that indicated no SMI, and said that the PASRR should have been reviewed upon admission and then resubmitted to include the Resident's SMI diagnoses and determination for a Level II evaluation, but it had not been. 45429 2. Resident #58 was admitted to the facility in April 2024, with diagnoses including Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder. Review of Resident #58's PASRR Level I Screening, dated 4/1/24, indicated No to the following questions: -Within the past two years, is the applicant known to have required one of the treatments or interventions listed below, that is, or may be due to a mental illness or mental disorder (MI/MD) < inpatient psychiatric hospitalization s <psychiatric day treatment <partial hospitalization program <intensive outpatient treatment <residential treatment <admission to a nursing facility <substance abuse disorder treatment <DMH involvement/case management <outpatient/community mental health treatment <other: -Within the past two years, did the applicant receive or would the applicant have benefited from one of the interventions listed below? <legal involvement <housing intervention <emergency mental health intervention (e.g., section 12 [transportation order to a hospital for individuals in crisis to see a Physician or Psychiatrist], crisis team involvement, suicide attempt, overdose) <other significant disruption to living situation for which supportive services were required -Currently or within the past six months, has the applicant had any limitation in major life activities in one of the areas listed below that is, or may be, due to mental illness or disorder? Major Life Activity Areas/Functional Impairments <Interpersonal functioning- serious difficulty interacting and or communicating effectively with others: illogical comments, fear of strangers, frequently isolating or avoiding others, excessive irritability, easily upset or anxious, hallucinations, or a possible history of eviction, altercations or unstable employment. <Concentration, persistence and pace- difficulty completing age-appropriate tasks and or/concentrating, completion timeliness, serious loss of interest, makes frequent errors, or requires assistance with activities/tasks that the applicant should be capable of accomplishing <Adaptation to change- significant difficulty adapting to typical change associated with employment, home, family, or social interactions, agitation, withdrawal due to adaptation difficulties, self-injurious behavior, self-mutilation, suicidal talks/ideations, physically violent or threatening, judicial intervention, severe appetite disturbance, excessive tearfulness. Review of the Referral Admission Information dated 4/1/24, indicated Resident #58 was referred to the psychiatric team while hospitalized for : -Failure to Thrive -agitation -mood lability (rapid exaggerated changes in mood) -pseudobulbar affect symptoms (a condition characterized by episodes of sudden uncontrolled and inappropriate laughter and crying). Further review of the Referral Admission Information indicated that Resident #58 was prescribed Zyprexa (anti-psychotic medication) and Prozac (anti-depressant) for treatment of these symptoms. Review of the facility policy titled PASRR, effective April 2018, indicated the following: -the facility will participate in a Level I screen for all potential admission regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI), intellectual disability (ID) or related condition. During an interview on 1/16/25 at 11:52 A.M., the Admissions Liaison said that she did not feel that Resident #58 should have been referred to the PASRR office for receiving psychiatric treatment while in the hospital for Failure to Thrive, Depression, pseudobulbar effect and ongoing Depression that prompted the Resident to be started on new psychotropic medications. During an interview on 1/16/25 at 12:35 P.M., Social Worker (SW) #1 said that based on the hospital discharge summary, the Level I PASRR should have been completed to indicate Resident #58 had a positive SMI screen and that the Resident should have been referred to the PASRR Office for a Level II PASRR evaluation to determine whether the Resident met criteria for SMI and to determine whether the Resident required specialized services for SMI.

Based on record review, observation and interview, the facility staff failed to provide adequate supervision and services to prevent accidents and hazards for 2 sampled residents (#12, #3) out of a total sample of 17 residents. In addition, the facility failed to provide an environment free from accident hazards in one area of the facility. Findings include: 1. For Resident #12, the facility staff failed to implement interventions and adequate supervision after the resident experienced three falls in order to help reduce the incidence of falls and injury. Resident #12 was admitted to the facility in 1/2016, with [DIAGNOSES REDACTED]. Review of the Fall Prevention Program, with a revision date of (8/2011), indicated that each resident will have an individual assessment and care plan which will address their specific needs related to fall risk. Review of the facility Accident/Incident Reporting Policy, dated (4/2013), indicated that the resident's care plan will be initiated or updated with appropriate interventions after an accident or incident. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/10/17, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderate cognitive impairment). a. Review of the Nurse's Notes, indicated that the resident had a fall on 3/26/16 at 3:15 P.M Review of the Occurrence Report, dated 3/26/16, indicated that the resident had a fall due to tripping on his/her catheter bag while transferring himself/herself onto the toilet. The intervention put in place after the fall was to remind the resident to call for assistance for transfers and to remind staff to apply urinary leg bag when out of bed. b. Review of the Nurse's Notes indicated that the resident had a fall on 7/6/16 and to review the Situation Background Assessment Recommendation (SBAR) notes for further information. Review of the SBAR, dated 7/6/17, indicated the resident self reported to the Certified Nurse Aide (CNA) at 12:35 P.M., that he/she was in the bathroom and had fallen and had gotten himself/herself back into bed. In addition, the resident was noted to have a fever, vomited twice and was experiencing slurred speech. Review of the Occurrence Report, dated 7/6/16, indicated that after the fall, the resident was transferred to the hospital and admitted with [DIAGNOSES REDACTED]. Upon return from the hospital, there was no new intervention put in place for the fall. c. Review of the Nurse's Notes, dated 7/18/16, indicated the resident was standing at the bathroom door at 3:10 A.M., with his/her Foley catheter stuck under the door, and was witnessed by staff member falling onto his/her right knee and sustaining a skin tear to the right knee. Review of the Occurrence Report, dated 7/18/16, indicated that there was no new intervention put into place after the fall. d. Review of the Nurse's Notes, dated 9/7/16, indicated the resident was heard screaming at 11:30 P.M., and was found lying flat on his/her back in the bathroom. The resident could not move his/her left leg and was transported to the hospital Review of the Incident Report Form, dated 9/12/16, indicated that the resident sustained [REDACTED]. e. Review of the Nurse's Notes, dated 1/15/17, indicated that the resident was in the bathroom at 12:15 P.M., and had pulled the call light to report that he/she had slipped and fallen while attempting to transfer onto the toilet from his/her wheelchair. Review of the Occurrence Report, dated 1/15/17, indicated that the resident had sustained a fall in the bathroom while attempting to self transfer from wheelchair onto toilet. The report was incomplete and no new interventions were documented. During an observation, on 3/22/17 at 11:00 A.M., the resident was awake and resting in bed. The resident responded to simple questions. A floor mat was noted on next to the bed from the window side. The resident's bed was in the low position. The call light was within the resident's reach and the motion sensor was in place and activated. During an interview, on 3/22/17 at 2:15 P.M., the Director of Nurses (DNS) said that falls that occurred on (7/6/16, 7/18/16 and 1/15/17), did not have new interventions put in place after the falls occurred. The DNS said the resident should have not been left alone in the bathroom on (1/15/17), when he/she sustained a fall as the resident was a high fall risk. She said she was aware the resident had a history of [REDACTED]. 2. For Resident #3, the facility staff failed to ensure the resident received adequate supervision to prevent accidents relative to the resident putting non-edible items in his/her mouth, which had a potential for resident harm. Resident #3 was admitted to the facility in 3/2010, with [DIAGNOSES REDACTED]. Review of the Risk of Injury Secondary to Ingestion of Non-Food Item Care Plan, initiated 2/9/16 and updated 1/19/17, indicated that the resident had ingested non-food items including chewing on clothes and eating paper/tissues. The interventions that were in place at this time included: notify the physician, observe for any adverse reaction, vital signs as ordered and as needed, observe the resident in areas where potential to ingest non-food items could occur. Review of the West Central Family and Counseling Progress Note, dated 1/27/17, indicated the resident was noted to put napkins and towels in his/her mouth. Review of the Annual MDS Assessment, with an ARD of 3/10/17, indicated that Resident #3 had unclear speech, was rarely understood or understands, exhibited severe cognitive impairment, required extensive assistance of 2 staff for transfers, required supervision of 1 staff with eating, and received a mechanically altered diet. On 3/17/17 at 2:45 P.M., the surveyor observed Resident #3 lying in bed with his/her eyes open. The resident was observed to be chewing on a clear small plastic cup. The surveyor observed another clear small plastic cup on the resident's bed near his/her left side. During an interview, on 3/17/17 at 2:45 P.M., Nurse #2 said that Resident #3 had a behavior of chewing on things. The surveyor observed Nurse #2 remove the small plastic cup from Resident #3's mouth. Nurse #2 said that the item Resident #3 was chewing on was a medication cup. The surveyor observed a thick milky white liquid to be inside the bottom edges of the medication cup that Nurse #2 had removed. Nurse #2 said that the resident needs to be supervised when given his/her medications, and that the resident sometimes grabs items to chew on. The surveyor observed Nurse #2 also remove the other medication cup from the resident's bed. On 3/22/17 at 10:50 A.M., the surveyor observed Resident #3 in the Activity Room, seated with other residents in a circle, facing a member of activities staff. The resident was seated in a wheel chair, and was observed by the surveyor, taking pieces off of a styrofoam cup and putting them into his/her mouth. The surveyor observed that approximately 1/4 of the styrofoam cup was missing. The surveyor observed the activities staff member remove the styrofoam cup from Resident #3. During this time, the surveyor was able to observe small pieces of white styrofoam present in the resident's mouth. Nurse #1 entered the activity room at this time, and the surveyor observed Nurse #1 remove pieces of white styrofoam from the resident's mouth. The resident was observed to be coughing during the time that Nurse #1 was attempting to remove the items from his/her mouth. During an interview, on 3/22/17 at 11:05 A.M., Nurse #1 said that he was able to take 2 larger pieces and 1 smaller piece of styrofoam out of Resident #3's mouth. He further said that he was not aware if the resident swallowed anything. 3. The facility failed to ensure the environment was free of accident hazards related to securely storing cleaning chemicals in a resident accessible area. During the environmental tour of the facility, on 3/16/17 at 1:35 P.M., the facility Housekeeping Managers office was observed with the Housekeeping Director. The office was located in the hallway to the left of the main lobby, across from a rehabilitation resident treatment room, and a few doors down from the business office where residents went to access their Personal Needs Accounts (PNA). Additionally, the facilities main dining room, where residents travel to and from to eat meals and also attend various activities, is located at the other end of the hallway. The Housekeeping Director was observed to access the office by pushing on the door with her hand as the door was not completely closed. On one side of the office, there was a multi-tier shelving unit that had housekeeping supplies including multiple types of cleaning chemicals stored on the shelves. During an interview, with the facility Housekeeping Manager on 3/16/17 at 1:35 P.M., she said that cleaning supplies were stored in a shed outside the building. She said that she stocked the shelves in her office with the cleaning chemicals and supplies for the facility housekeepers' to access and stock their cleaning carts. On 3/17/17 at 10:20 A.M., the Housekeeping Managers office door was observed to be open with no one inside. On 3/22/17 at 7:25 A.M., the Housekeeping Managers office was observed to have the door wide open, with no one inside. The metal shelving unit, located in the office, was observed to be stocked with multiple plastic bottles of various cleaning chemicals such as Eliminator Concentrated Odor Neutralizer, 44 ACE Disinfectant Cleaner, Tru Clean Liquid Cleaner and gallon of Clorox Bleach. On 3/22/17 at 8:50 A.M., with the Director of Nurses Services (DNS) present, the Housekeeping Directors office was observed to be open and the door unlocked. The DNS said that the door is supposed to be locked due to the storage of chemicals and it is not. She further said that residents use the hallway unsupervised as it is adjacent to the lobby. They also pass through the hallway to access their PNA accounts from the business office and rehabilitative services across the hall.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #1 initiated cardiopulmonary resuscitation (CPR) for Resident #1, per Facility policies regarding Advance Directives and CPR. Findings include: A review of the Facility's Advance Directives Policy indicated the licensed nurse ensures that the residents' advanced directives were honored and executed per the clinical record and the physician orders. A review of the Facility's CPR Policy indicated that CPR would be administered to a resident in the event of a cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR (do not resuscitate) order. The CPR Policy indicated that the code status must be written in the physician orders. The physician's orders [REDACTED].#1 was a full code status. CNA #1 and CNA #2's written statements, dated [DATE], indicated that the nurse was immediately notified that Resident #1 was found unresponsive at 5:30 A.M. on [DATE]. The Surveyor interviewed Nurse #1 at 10:00 A.M. on [DATE]. Nurse #1 said, at about 5:30 A.M. on [DATE], she was summoned by CNA #1 to Resident #1's bedside during morning personal care rounds because Resident #1 was unresponsive. Nurse #1 said she observed that Resident #1 was not breathing and had no pulse but was still warm to touch. Nurse #1 said she continued her morning medication pass and then it slipped her mind that she should check Resident #1's code status and request an RN (registered nurse) pronouncement. Nurse #1 said she finished her morning medication pass at about 6:30 A.M. and then remembered that Resident #1 had died and Nurse #1 asked CNA #3 to notify Nurse #2, a registered nurse on another unit, that Resident #1 had died so that she could help obtain an RN pronouncement for Resident #1. Nurse #1 said she had not initiated CPR because Resident #1 was "too old and sick," she assumed Resident #1 had a do not resuscitate status but failed to check the advanced directives or physician orders [REDACTED]. .

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #1 initiated cardiopulmonary resuscitation (CPR) for Resident #1, per Facility policies regarding Advance Directives and CPR. Nurse #1 said, at about 5:30 A.M. on [DATE], she was summoned by CNA #1 to Resident #1's bedside during morning personal care rounds because Resident #1 was unresponsive. Nurse #1 said she observed that Resident #1 was not breathing and had no pulse, but he/she was still warm to touch. Nurse #1 said she continued her morning medication pass and then it slipped her mind that she should check Resident #1's code status. Findings include: A review of the Facility's Advance Directives Policy indicated the licensed nurse ensures that the residents' advanced directives were honored and executed per the clinical record and the physician orders. A review of the Facility's CPR Policy indicated that CPR would be administered to a resident in the event of a cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR (do not resuscitate) order. The CPR Policy indicated that the code status must be written in the physician orders. The Record Of Admission Form indicated that Resident #1 was admitted to the Facility September, 2012 and had [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#1 was a full code status. The Surveyor interviewed the Director of Social Services at 1:30 P.M. on [DATE]. The Director of Social Services said that on admission Resident #1 and his/her family expressed the desire for Resident #1 to remain a full code status. The Director of Social Services initial psychosocial profile, dated [DATE], indicated that Resident #1 was a full code status. The plan of care, dated [DATE], indicated that Resident #1 remained a full code status. The Admission Minimum Data Set (MDS) assessment, completed on [DATE], indicated that Resident #1 had no advance directives. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 2:30 P.M. on [DATE]. The Surveyor interviewed CNA #2 at 11:45 A.M. on [DATE]. CNA #1 and CNA #2 said they were assigned to Resident #1's unit during the night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]). CNA #1 and CNA #2 said Resident #1 was unresponsive during morning personal care rounds at approximately 5:30 A.M. CNA #1 said Nurse #1 was notified that Resident #1 was unresponsive at 5:30 A.M. on ,[DATE]; Nurse #1 told her to continue the residents' morning personal care, and that she would take care of Resident #1. CNA #1 and CNA #2's written statements, dated [DATE], indicated that the nurse was immediately notified that Resident #1 was found unresponsive at 5:30 A.M. on [DATE]. The Surveyor interviewed Nurse #1 at 10:00 A.M. on [DATE]. Nurse #1 said, at about 5:30 A.M. on [DATE], she was summoned by CNA #1 to Resident #1's bedside during morning personal care rounds because Resident #1 was unresponsive. Nurse #1 said she observed that Resident #1 was not breathing and had no pulse but was still warm to touch. Nurse #1 said she continued her morning medication pass and then it slipped her mind that she should check Resident #1's code status and request an RN (registered nurse) pronouncement. Nurse #1 said she finished her morning medication pass at about 6:30 A.M. and then remembered that Resident #1 had died and Nurse #1 asked CNA #3 to notify Nurse #2, a registered nurse on another unit, that Resident #1 had died so that she could help obtain an RN pronouncement for Resident #1. Nurse #1 said she had not initiated CPR because Resident #1 was "too old and sick," she assumed Resident #1 had a do not resuscitate status but failed to check the advanced directives or physician orders [REDACTED]. The Surveyor interviewed CNA #3 at 12:00 P.M. on [DATE]. CNA #3 said she was assigned to another unit from 6:00 A.M. to 2:00 P.M. on [DATE]. CNA #3 said she went to Resident #1's unit at about 6:30 A.M. to borrow some supplies. CNA #3 said Nurse #1 asked her to tell Nurse #2, who was the nurse on CNA #3's unit, that Resident #1 had died . . The Surveyor interviewed Nurse #2 at 7:10 A.M. on [DATE]. Nurse #2 said she was assigned to another unit during the night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]) and that she routinely did the RN pronouncements. Nurse #2 said at about 6:30 A.M. on [DATE], she received a message from CNA #3 that a resident had died on Resident #1's unit, and she assumed that she was needed to do an RN pronouncement. Nurse #2 said no code blue (to alert staff that emergency help was needed) was called. Nurse #2 said at about 6:50 A.M. Nurse #1 came to her unit and asked her when she was coming to Resident #1's unit to help with the death. Nurse #2 told Nurse #1 when she completed the morning medication pass she would help her with Resident #1. Nurse #2 said she assumed it was for an RN pronouncement as no report was given that this was a code blue or an emergency. Nurse #2 said Nurse #1 returned to Resident #1's unit. Nurse #2's written statement, dated [DATE], indicated that at about 6:30 A.M. she was told by CNA #3 that a resident had died on another unit and that Nurse #1 (licensed practical nurse) requested assistance from Nurse #2 who was a registered nurse. Nurse #2's written statement indicated that she believed she was needed to provide an RN pronouncement because she was told a resident had died because there was no mention that emergency care was requested, and that a code blue was not called. Nurse #2's written statement indicated that at about 6:50 A.M. Nurse #1 arrived on Nurse #2's unit to remind her that she needed her help. Nurse #2's written statement indicated that Nurse #2 assured Nurse #1 that she would help her when she finished her medication pass. The Surveyor interviewed Nurse #3 at 9:00 A.M. on [DATE]. Nurse #3 said he reported to duty shortly after 7:00 A.M. on [DATE]. The punched time card, dated [DATE], indicated Nurse #3 punched in for duty at 7:05 A.M. on [DATE]. Nurse #3 said he arrived for duty shortly after 7:00 A.M. on [DATE] and was calmly told by Nurse #1 that Resident #1 had died about 5:00 A.M. and Nurse #1 discussed whether or not to notify the family, consider CPR, or ask the doctor for an RN pronouncement. Nurse #3 said he immediately asked if CPR was initiated or if Nurse #1 checked Resident #1's code status. Nurse #3 said Nurse #1 responded, no, to both questions, thus he confirmed the full code status, and he initiated CPR. Nurse #3 said 911 and a code blue was called. Nurse #3 said CPR was stopped by the Emergency Medical Technicians because rigor mortis (major joints are immovable) was present. Nurse #3's written statement, dated [DATE], indicated upon arriving on Resident #1 unit to start his day shift he was notified by Nurse #1 that Resident #1 had died about 5:00 A.M. and Nurse #1 discussed whether or not to notify the family and ask the doctor for an RN pronouncement. Nurse #3's written statement indicated he asked what Resident #1's code status was and if CPR had been performed. Nurse #3's written statement indicated that Nurse #1 said she was not sure of Resident #1's code status and had not initiated CPR. Nurse #3's written statement indicated he confirmed that Resident #1 was a full code, that CPR was initiated without success, and Resident #1 was pronounced deceased at 7:47 A.M. on [DATE]. Nurse #3's day shift nurse's note, dated [DATE], indicated he arrived for day shift (7:00 A.M. to 3:00 P.M.) duty and Nurse #1 discussed with him whether or not to start CPR or to call the doctor for an RN pronouncement before establishing Resident #1's code status. Nurse #3's day shift nurse's note, dated [DATE], indicated CPR was initiated without success and after EMT's arrived an order was obtained for an RN pronouncement. Nurse #2 said the licensed nurses on the units were educated to check the advanced directives that were in the clinical record and in the physician orders. Nurse #2 said the Advanced Directives were reviewed by the assigned night shift nurse at the beginning of the shift because the code status for each resident was listed on the shift report. The Director of Nurses was interviewed at 7:00 A.M. and 4:15 P.M. on [DATE]. The DON said staff was educated regarding the Facility's Advance Directives Policy during orientation. The policy indicated that the licensed nurse ensured that the residents' advanced directives were honored and executed per the clinical record and the physician orders. A review of the Facility's Advance Directives Policy indicated the licensed nurse ensures that the residents' advanced directives were honored and executed per the clinical record and the physician orders. The DON said staff were educated on the Facility's CPR Policy during orientation. The policy indicated that CPR would be administered to a resident in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. A review of the Facility's CPR Policy indicated that CPR would be administered to a resident in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. Nurse #1 said she was aware that CPR was initiated in the event of cardiac or [MEDICAL CONDITION] arrest unless the resident had a DNR order. Nurse #1 said she had not checked Resident #1's code status. Nurse #1 said she assumed Resident #1 was a DNR status because Resident #1 "was too old and sick." The DON said staff were educated on CPR requirements, as part of the Advanced Directives Policy, during orientation and re-educated after the incident. The DON said Nurse #1 was terminated for not initiating CPR when Resident #1 was found not breathing, with no pulse, and remained warmed to touch. The DON said staff were re-educated, between [DATE] - [DATE], and on [DATE], regarding the residents advanced directives, physician orders, code blue, and CPR requirements.