Every finding on record at Fall River Healthcare

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required transfer to the Hospital Emergency Department for an evaluation, the Facility failed ensure they sent a copy of their Notice of Intent to Discharge him/her to a representative of the Office of the Long-Term Care Ombudsman, as required. Findings include: The Facility Transfer or Discharge Notice Policy, last revised 11/2024, indicated that a resident and/or his/her representative, will be given a thirty-day written notice of an impending transfer or discharge from the Facility. The Policy indicated that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. Review of Resident #1's clinical record indicated he/she was admitted to the Facility during July 2025 and his/her diagnoses included multiple sclerosis, major depressive disorder, anxiety disorder and tobacco use. Resident #1's Care Plan related to resident's wish to discharge to the community, dated as initiated 7/16/25, indicated that Resident #1 would communicate an understanding of the discharge plan and interventions included preparing and giving him/her the contact information for community referrals as needed. During a telephone interview on 6/29/26 at 9:03 A.M., the Ombudsman said that the Facility does not send them a copy of each individual resident discharge notice but only provided them [Ombudsman office] with a Weekly Report entitled Ombudsman Notification of Facility Initiated Transfer/Discharge. The Ombudsman said that the Weekly Report indicates which residents had been discharged during the prior week and provides a generic location, such as home or to hospital. The Ombudsman said the Report also does not indicate the specific address where the Facility planned to discharged residents. During an interview on 6/29/26 at 3:40 P.M., the Director of Social Service provided the surveyor with a copy of the Ombudsman Notification of Facility Initiated Transfer/Discharge Reports, dated as having been faxed to the Ombudsman on 6/08/26 and 6/19/26. The Reports did not indicate the specific addresses where residents had been discharged . The Director of Social Service said that she faxed the Report to the Ombudsman's office instead of faxing each resident's discharge or transfer notice because that was what had been done by her predecessor. The Director of Social Services said she was not aware that the Ombudsman Office required additional information, or that the regulations required they were sent a copy of discharge notices.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required an atypical antipsychotic medication for major depressive disorder and anxiety disorder, the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility following a hospitalization, his/her medication orders were not accurately reconciled by nursing resulting in him/her being administered four extra doses of his/her antipsychotic in error. Findings include: Review of the Reconciliation of Medication on admission Policy, dated 11/20/24, indicated that the purpose of the procedure was to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The Guidelines for the Policy indicated that medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/19/26, indicated Resident #1 was hospitalized on [DATE] following an incident in which he/she intentionally drove his/her electric wheelchair into a staff member's leg. Review of Resident #1's medical record indicated he/she was initially admitted to the Facility in July 2025, diagnoses include multiple sclerosis, major depressive disorder, and anxiety disorder. Review of Resident #1's Physician's Orders for June 2026 indicated that at the time of his/her transfer to the hospital on 6/05/26, his/her medication orders included risperidone (atypical antipsychotic medication used to rebalance neurotransmitters in the brain to help stabilize mood, thoughts, and behaviors) 0.25 milligrams (mg) once a day in the evening. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that upon return to the Facility, he/she should continue risperidone 0.5 mg tablet daily. Further review of the Hospital Discharge Summary indicated that there were no recommendations, instruction or order for Resident #1 related to risperidone 0.25 mg. There was no documentation in Resident #1's medical to support that upon his/her readmission to the facility that nursing clarified the risperidone orders with the physician. Review of Resident #1's Facility Physician's Orders, dated 06/25/26, indicated he/she had orders to be administered risperidone 0.5 mg in the morning and risperidone 0.25 mg at bedtime. Review of Resident #1's Medication Administration Record (MAR), dated 06/25/26 through 06/29/26, indicated Resident #1 received risperidone 0.5 mg every morning and from 6/26/26 through 6/29/26 he/she received risperidone 0.25 mg at bedtime. During an interview on 06/30/26 at 2:10 P.M., the Director of Nurses (DON) said she was unaware of Resident #1's significant medication error until being questioned about Resident #1's medications by the Surveyor on 6/29/26. The DON said when she reviewed Resident #1's Hospital Discharge Record, she discovered there had been a transcription error with Resident #1's risperidone medication, upon his/her readmission to the facility. The DON said that she spoke with the Resident #1's physician on 6/30/26 who said he wanted Resident #1 to receive risperidone 0.25 mg in the evening, and that Resident #1 should not have been receiving risperidone 0.5 mg.

Based on records reviewed and interviews, for two of three sampled residents (Residents #2 and #3) who were severely cognitively impaired, the Facility failed to ensure they were treated in a dignified and respectful manner, when in January 2026 they both experienced an incident involving physical contact initiated by Resident #1 (who was also severely cognitively impaired), which was unwanted and without their consent.Findings include:Review of the Facility Policy titled Resident Rights, dated as revised 1/2024, indicated the residents had the right to a dignified existence and to be treated with respect and dignity.Resident #1 was admitted to the Facility in October 2025, diagnoses included psychotic disorder and Alzheimer's Disease.Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 1/23/26, indicated Resident #1's cognitive patterns were severely impaired.Review of Resident #1's Medical Record indicated his/her Health Care Proxy had been activated by the physician on 1/19/26.Resident #2 was admitted to the Facility in December 2022, diagnoses included unspecified dementia and psychotic disturbance.Resident #2's Annual MDS Assessment, dated 11/14/25, indicated Resident #1's cognitive patterns were severely impaired.Review of Resident #2's Medical Record indicated the court appointed a guardian for him/her on 1/31/23.Resident #3 was admitted to the Facility during April 2025, diagnoses included cerebral infarction and adjustment disorder with anxiety.Resident #3's Quarterly MDS Assessment, dated 10/10/25, indicated Resident #3's cognitive patterns were severely impaired.Review of Resident #3's Medical Record indicated the court appointed a guardian for him/her on 7/29/25.Review of the Health Care Facility Reporting System (HCFRS) indicated the Facility reported the following incidents to the Department of Public Health:-on 1/09/26 Resident #1 kissed Resident #3 and hugged Resident #2, without either residents consent;-on 1/16/26, Resident #1 massaged Resident #3's shoulders without his/her consent, and,-on 2/01/26, Resident #1 touched/groped Resident #2's breast and groin area over his/her clothes without his/her consent.During interviews on 2/09/26 at 12:35 P.M. and 12:50 P.M., Social Workers #1 and #2 said that they met with Resident #1 on 1/12/26 and 1/16/26. Social Workers #1 and #2 said that they discussed personal boundaries among residents with Resident #1 and although in the moment he/she verbalized understanding, that almost immediately following the conversations he/she appeared to forget that they had spoken and/or forgot the content of their conversation.During a telephone interview on 2/17/26 at 11:30 A.M., the Director of Nursing said that Resident #2 was visibly upset and shaken following the incident on 2/10/26 in which Resident #1 touched his/her breast and groin area over his/her clothes. The Director of Nursing said that although Resident #1 was on 15 minutes checks at the time of the incident (and has been since 1/09/26) that after the 2/01/26 incident, he/she was moved to another Facility unit for Resident #2's safety and sanity.

Based on interview and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after repeated concerns brought forward by the Resident Council regarding long call light response times the facility failed to implement their policy and procedures to include the Resident Council concerns as a QAPI project. Findings include:Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated as revised in June 2019 indicated:-the purpose of the Steering Committee was to review and analyze facility related data and direct appropriate actions for the facility response-the appointment of a QAPI team may be necessary to explore the depth of the issue and identify the root cause so that interventions are appropriately resolved-the QAPI plan will address Quality of Life through resident/family concerns brought up at Resident or Family Committee meetings-Center leadership, including, but not limited to Administrator, Director of Nurses, Social Services, and Activity Director meet monthly to address life concerns. Review of the Resident Council Minutes, dated 7/16/25, indicated call lights continued to be monitored and when asked the residents responded that they could not get help or care without waiting a long time and call lights were not answered in a timely manner. Review of the Resident Council Minutes, dated 8/13/25, indicated call lights continued to be monitored, and the residents added that on weekends call lights were not answered in a timely manner; the residents requested and were in agreement to file a grievance. Review of the Resident Council Minutes, dated 9/17/25, indicated call lights continued to be monitored and residents asked for auditing of call lights on the second shift (3:00 P.M. to 11:00 P.M.) and when asked if call lights were answered in a timely manner the residents indicated not on the second shift. Review of the Resident Council Minutes, dated 10/15/25, indicated call lights continued to be monitored and a grievance was filed. Review of the Resident Council Minutes, dated 11/12/25, indicated call lights on weekends and second shift continue to be a work in progress. On 12/17/25 at 1:30 P.M., the surveyor held a group meeting with 13 residents in attendance. The residents said every month they bring up the concerns of call light wait times and said the problem continued on weekends and second shift. They said they have waited 45 minutes to an hour for a staff member to answer their call lights.During an interview on 12/17/25 at 3:20 P.M., the Activity Director said the residents in Resident Council had voiced concerns mostly about the call light response wait time on the second shift and weekends. She said management staff were completing audits during the day shifts, but she was not sure who audited the second shift or the weekends. She said there was a scheduled manager on duty during the weekends, but the audits were not part of the responsibilities. During an interview on 12/17/25 at 3:40 P.M., the Administrator said the audits had recently started and the management staff were responsible for conducting audits on call lights and bringing the results to the Assistant Administrator. He said the staff responsible for conducting the audits provided just-in time education to staff regarding answering call lights and there was no formal education noted at these times. He said he had not reviewed the December 2025 audits and had not realized the residents had waited 20 and 25 minutes for call lights to be answered. He said he did not know the residents from Resident Council had voiced they had waited 45 minutes to an hour. He said he has previously attended Resident Council meetings and had not inquired how long the residents wait. The Administrator said he started working at the facility at the end of September and he could not be sure if there had been a QAPI initiated to improve the call light wait times. He reviewed the QAPI projects and said there was not a current project to address the Resident Council concerns regarding long call light wait times. During an interview on 12/17/25 at 4:00 P.M., the Assistant Administrator said she had been working at the facility through the changes in Administration and there was not a QAPI project to address Resident Council concerns of long call light wait times.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding long call light wait times were acted upon to resolve the issue.Findings include:Review of the facility's policy titled Resident Council, dated as revised in February 2024, indicated the facility would establish and maintain an active Resident Council with the basic goal of promoting the highest Quality of Life for each resident. The process included Department Heads responding to grievances addressed in the minutes in writing before the next meeting. Review of the Resident Council Minutes, dated 7/16/25, indicated call lights continued to be monitored and when asked the residents responded that they could not get help or care without waiting a long time and call lights were not answered in a timely manner. Review of the Resident Council Minutes, dated 8/13/25, indicated call lights continued to be monitored, and the residents added that on weekends call lights were not answered in a timely manner; the residents requested and were in agreement to file a grievance. Review of the Resident Council Minutes, dated 9/17/25, indicated call lights continued to be monitored and residents asked for auditing of call lights on the second shift (3:00 P.M. to 11:00 P.M.) and when asked if call lights were answered in a timely manner the residents indicated not on the second shift. Review of the Resident Council Minutes, dated 10/15/25, indicated call lights continued to be monitored and a grievance was filed. Review of the Resident Council Minutes, dated 11/12/25, indicated call lights on weekends and second shift continue to be a work in progress. On 12/17/25 at 1:30 P.M., the surveyor held a group meeting with 13 residents in attendance. The residents said every month they bring up the concerns of call light wait times and said the problem continued on weekends and second shift. They said they can wait 45 minutes to an hour for a staff member to answer their call lights and did not feel the facility had followed up with the Resident Council on a plan. The surveyor requested Resident Council meeting follow-up from the Activity Director and was provided staff education sheets.Review of the staff education sheets indicated the following related to call lights:7/22/25: Review of answering call light policy signed by nine staff members9/18/25: Education on customer service including answering call lights provided to 50 staff members (7 who signed-in twice for a total of 43 staff members), 11 of which worked on the second shift.10/15/25: Education on customer service including answering call lights with the same signatures, in the same order, on the same pages as the training from 9/18/25. During an interview on 12/17/25 at 4:42 P.M., the Staff Development Coordinator said she was unable to find the original sign in sheets for the trainings from 9/18/25 and 10/15/25 and that although she felt the staff had been educated multiple times on call light response time she said the staff did not sign in on both 9/18/25 and 10/15/25. During an interview on 12/17/25 at 9:20 A.M., the Activity Director said the staff had been conducting audits on call lights, staff wearing name tags, and staff using headphones. She said the audit responses were provided to the Assistant Administrator and does not know what the follow up to the audits was. The Activity Director provided the surveyor with facility conducted audits for the month of December 2025. Review of the audits failed to indicate any audits were conducted on the weekends. The audits indicated call light response time for the second shift was observed on 2 out of 16 days. The audit forms inquired if call lights were answered timely and both second shift observations answered no. Observations on the first shift (7:00 A.M. to 3:00 P.M.) indicated on 12/2/25 one resident waited 25 minutes for the call light to be answered, one resident waited 20 minutes and for another resident a staff member had shut off the call light from the nurses' station without going to see the resident and on 12/3/25 one resident waited 25 minutes and one resident waited 20 minutes. During an interview on 12/17/25 at 3:20 P.M., the Activity Director said the residents in Resident Council had voiced concerns mostly about the call light response wait time on the second shift and weekends, she said the residents had noted there had been some improvement in the wait time during the first shift. She said she was not sure who audited the second shift or the weekends. She said there was a scheduled manager on duty during the weekends, but the audits were not part of the responsibilities. During an interview on 12/17/25 at 3:40 P.M., the Administrator said the audits had recently started and the management staff were responsible for conducting audits on call lights and to bring the results to the Assistant Administrator. He said he had not reviewed the December 2025 audits and had not realized the residents had waited 20 and 25 minutes for call lights to be answered. He said he did not know the residents from Resident Council had voiced they had waited 45 minutes to an hour and had not inquired how long they wait. The surveyor reviewed the grievance book with the Administrator which did not include the grievances from the August 2025 and October 2025 Resident Council meetings. The Administrator said he would have to look for these grievances and their resolutions. During an interview on 12/18/25 at 10:27 A.M., the Administrator said there were no grievance forms for the August 2025 or October 2025 Resident Council meetings and no follow up to the grievances. Refer to F865

Based on document review and interviews, the facility failed to ensure residents had access to their personal funds. Specifically, the facility failed to make funds available for Resident #10 within three banking days for requests in the amount of $50 or more and failed to make funds available for same day requests for cash amounts less than $50.Findings include:Review of the facility's Resident Handbook, undated, indicated the facility could assist with the management of Personal Funds. The Handbook indicated Deposits into these accounts may be made by mail or in person during normal business office hours. For withdrawals from a resident's personal funds account after the Business Office hours, the resident may contact his/her unit supervisor who will assist the resident with the transaction. Review of the facility's Resident Handbook failed to indicate a process for withdrawals during business office hours, how much personal funds could be withdrawn at a time, or what the business office hours were. During an interview on 12/15/25 at 10:00 A.M., the Ombudsman said there were concerns with the Business Office distributing funds to all residents who were requesting their funds and it was on a first come first serve basis and that, in particular, Resident #10 could not access his/her personal funds to purchase clothing and had been told to purchase clothing from a catalog. On 12/17/25 at 1:30 P.M., the surveyor held a group meeting with 13 residents in attendance. During interviews at this time, five out of 13 residents said they had the facility manage their personal funds, while the other residents said they held their personal funds off site. The five residents said the Receptionist was responsible for distributing funds from their personal funds accounts from 10:00 A.M. to 2:00 P.M. and would often run out of cash. They said they accessed funds on a first come first serve basis and most residents would request $50 at a time and then the funds would run out leading to times where they could not access their funds. They said on the weekends they only had access to funds if there was a receptionist working, which was not every weekend.During an interview on 12/17/25 at 11:15 A.M., Resident #10 said the process to withdraw money from his/her personal account at the facility was to request money from the Receptionist. Resident #10 said he/she could only take out $50 per day and there were days the facility did not have funds available to distribute to residents. Resident #10 said he/she had called down to the Receptionist this morning and was told there was no cash available to distribute for the residents. In addition, Resident #10 said he/she had wanted to buy new clothes and a friend was going to go shopping for the clothing. He/she said they had requested to withdraw $300 for clothing and were told they could not have $300 of their own money at once and they could either order clothing from a catalog (a particular clothing company the facility utilized) or the friend could purchase the clothing with their money, submit the receipt and be reimbursed. During an interview on 12/17/25 at 11:50 A.M., the Business Office Assistant said she had worked at the facility since July 2025 and did not handle anything regarding resident personal funds. She said the Receptionist was responsible for distributing money to residents from their personal needs accounts. During an interview on 12/17/25 at 11:51 A.M., the Business Office Manager said she had started working at the facility this month and was still in training. During an interview on 12/17/25 at 12:00 P.M., the Receptionist said she provided banking hours from 10:00 A.M. to 3:30 P.M. She said a lot of residents would request $50 at a time and the bank would run out of money. She said the process was for her to submit the information of money withdrawn from the bank each day and then the corporate office would respond by adding money to an ATM card, she would then go to the bank and withdraw the money. She said the maximum amount of money added to the ATM card was $480 and that was the amount she could withdraw. She said the resident bank would then only have $480 and she would tell the residents to come down early to withdraw their money because it was a first come first serve basis. She said if the first 10 residents were to request $50 each that was why the bank would run out of money and funds were not available for other residents. The Receptionist said when Resident #10 had called down earlier she had informed the Resident there was no money available because she had not had time to go to the bank yet, she added the facility bank had the money at the time of this interview. She said the maximum amount of funds a Resident could take out per day was $50. She said even if a resident were to request funds ahead of time they could not withdraw more than $50 per day from their own personal funds. She said Resident #10 could not have $300 from their personal funds account because that would take almost all of the $480 from the facility bank. She said the friend of Resident #10 could go shopping with their own money and submit a receipt to the facility for reimbursement from the Resident's personal funds. During an interview on 12/17/25 at 3:10 P.M., the Quality Assurance Liaison said the process for resident personal funds accounts was that the facility was provided with a global cash card to withdraw money from an external bank. She said when money was withdrawn by residents from the petty cash box (facility bank) the Receptionist submitted withdrawal slips and the corporation would add money to the global cash card for withdrawal. She said the facility was allowed to keep $1000 in cash in the petty cash box but that the ATM withdrawal limit was $480 per day. She said the Receptionist goes to the bank to withdraw money about once or twice a week and does not have time to go more. She said she was not aware that the petty cash box did not have $1000 in it and that residents were being told they could not access funds because the petty cash box (facility bank) was out of money. She said if a Resident has funds they can request more than $50 ahead of time. She said Resident #10 should have been provided with the money he/she requested and should not have been told no by the Receptionist.

Based on observations, interview, and record review, the facility failed to evaluate and assess one Resident (#97), out of a total sample of 34 residents after an unplanned 11.29% significant weight loss in six months had been identified. Specifically, the facility failed to assess and evaluate the resident for more than two months after the significant weight loss had been identified. Findings include: Review of the facility's policy titled Weight Measurement, dated as last revised 11/2025, indicated but was not limited to the following:-Weights will be obtained monthly at the beginning of the month.-All residents with significant weight changes will be reweighed to ensure accuracy of the weight. If the reweight indicates significant weight change, the resident and/or representative and interdisciplinary team (IDT) will be notified, and plan of care will be revised as warranted. Resident #97 was admitted to the facility in April 2025 with diagnoses which include abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. Review of the Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated Resident #97 scored 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating he/she had severe cognitive impairment, and had undesired/unplanned weight loss of 5% in the last month or 10% in the last six months. During an interview on 12/16/25 at 10:00 A.M., Resident #97 said the food is terrible, poor quality, small portions, and odd pairings. Additionally, he/she said they were picky since admission because the food is weird and they have lost weight. Review of the Comprehensive Care Plan indicated but was not limited to the following:FOCUS: NUTRITION: Resident is at nutritional risk.GOAL: The resident will have no significant changes in weight through review date.INTERVENTIONS: Monitor/Record weights per facility protocol/MD orders; Diet Consult as needed. Review of the Physician's Orders indicated Resident #97's diet was Heart Healthy, CCHO (Controlled Carbohydrate for diabetic management). No nutritional supplements were ordered. Review of the Weight Summary for Resident #97 indicated but was not limited to the following:-4/9/25: 124 pounds (lbs.)-5/7/25: 118 lbs.-6/4/25: 118 lbs.-7/11/25: 117 lbs.-8/7/25: 115 lbs.-9/3/25: 115 lbs.-10/8/25: 110 lbs. Resident #97's weight was down 4.35% in one month; 5.98% in three months; and 11.29% in six months. Review of the Nurse Practitioner (NP) progress note, dated 9/19/25, indicated Resident #97 had a weight loss since admission, about 9 lbs., and they wanted the Dietitian to follow up.Review of the nursing progress note, dated 9/19/25, indicated the NP was in the facility, aware of weight loss, and ordered a Dietitian consult and the Registered Dietitian (RD) was made aware. Review of the Medical Nutrition Therapy Assessment, dated 10/7/25, indicated but was not limited to the following:-Assessment Type: Quarterly-Does the Resident have a recent weight: Yes: 115 lbs. on 9/3/25.-Weight 30 days ago: (left blank)-% Weight Change in 30 days: (left blank)-Weight 90 days ago: 117-% Weight Change in 90 days: (left blank)-Weight 180 days ago: 124-% Weight Change in 180 days: (left blank)-Summary: Resident has maintained a stable weight, with gradual weight loss since their admission 3 months ago. No nutritional interventions at this time. The RD failed to ensure a recent weight was obtained and used in the evaluation for an accurate assessment of Resident #97's status. Review of the Nursing, RD, MD, and Nurse Practitioner (NP) progress notes failed to indicate Resident #97 had been assessed and evaluated regarding the weight loss since the significant weight loss had been identified on 10/8/25 (72 days). During an interview on 12/19/25 at 12:03 P.M., Nurse #4 said she was not sure of the facility policy on weights, reweights, and notifications. During an interview on 12/19/25 at 12:13 P.M., Unit Manager #2 said anytime the new weight is down or up three pounds from the previous weight, it should be rechecked to confirm accuracy of the loss or gain. She said the computer program should generate an alert for the RD to see, but if we (nursing) noticed the weight loss the RD would be notified to evaluate for interventions. She said with any significant weight loss, the resident should be discussed at risk, the RD usually makes recommendations and writes a note and/or the MD/NP. She said she was not sure why this weight loss was not addressed. During an interview on 12/19/25 at 1:35 P.M., the Wound Nurse said weights are done monthly and must be done before the 10th. She said if it is off by 3 lbs. then it should be rechecked by the next day to confirm, then resident representative, RD, MD/NP would all be notified, and he/she would be evaluated for additional interventions within a week by the RD and/or MD/NP. She said significant weight loss should be documented and addressed timely, and this was not. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said if the weight loss is 5% change in a month, they should recheck the weight to confirm. She said the RD is here regularly and there should be a provider response to address the weight loss within a week. Additionally, she said although the one-month weight loss is just under 5% the six-month weight loss was >10% so it should have triggered as significant weight loss in the system and been addressed. During an interview on 12/19/25 at 2:54 P.M., the Corporate Dietitian said the trigger for a reweight is 5%, and although the one-month weight loss (115 lbs. down to 110 lbs.) was just under 5%, the six-month weight loss (124 lbs. down to 110 lbs.) was over 10% so it automatically triggers an alert on the dashboard. She said the RD reviews the dashboard every day they are in the building, which is typically five days a week. She said the alert stays on the dashboard for 30 days unless it is cleared out. She said this alert was never cleared out, so it was on the dashboard for 30 days and then fell off. She said the previous RD left the first week of November which would have been around the time the alert fell off. She said she had been following the residents since then and Resident #97's weight has been stable at 110 lbs. for the last three months, so it is no longer triggering. When the significant weight loss was identified in October, it should have been addressed by the RD, and at the very minimum, a progress note should have been written and that did not happen.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of three nurses observed during the medication pass made three errors out of 31 opportunities, resulting in a medication error rate of 9.68%. Those errors impacted two Residents (#77 and #62). Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated and revised April 11, 2018, indicated but was not limited to the following: Nurses Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.Review of the facility's policy titled Administering Medications, dated as revised September 2024, indicated but was not limited to the following:-Medications are administered in a safe and timely manner, and as prescribed.-Medications are administered in accordance with prescriber orders, including any required time frame.-Medications may be administered one (1) hour before or after the prescribed time, unless otherwise specified.A. Resident #77 was admitted to the facility in November 2024 with diagnoses which include hypertension (high blood pressure) and depression.On 12/17/25 at 8:30 A.M., the surveyor observed Nurse #1 prepare and administer medication for Resident #77. Prior to preparing medication, Nurse #1 obtained Resident #77's blood pressure, resulting in a result of 108/75. Nurse #1 said she would not administer Resident #77 his/her propranolol (used to lower blood pressure) because his/her blood pressure was below 110. Nurse #1 could not locate Resident #77s sertraline (antidepressant) in her medication cart and reported she could not administer the medication to Resident #77 because it was not available from the pharmacy.Review of the Physician's Orders indicated but were not limited to following:-propranolol 20 milligrams (mg) by mouth two times a day, scheduled for 9:00 A.M. and 9:00 P.M. (dated 8/18/25)-sertraline 100 mg by mouth in the morning for depression, scheduled for 9:00 A.M. (dated 12/16/25)Further review of the propranolol order failed to indicate a parameter was in place for the blood pressure to not be administered if his/her blood pressure was below 110.Review of the Medication Administration Record (MAR) indicated but was not limited to the following:-propranolol was not signed off as administered, and was marked with an 8, indicating other. -sertraline was not signed off as administered and was marked with an 8, indicating other.During an interview on 12/17/25 at 12:02 P.M., Nurse #1 said she did not administer Resident #77 propranolol because she did not want to drop his/her blood pressure. Nurse #1 said the order did not have a parameter indicating it should be held if his/her blood pressure was below a certain number; she just used her nursing judgment. Nurse #1 said she located Resident #77's sertraline, the surveyor asked to observe the card the dose was administered from and Nurse #1 said that although she had located the sertraline she had not administered it.B. Resident #62 was admitted to the facility in October 2017 with diagnoses which included hypertension and diabetes mellitus.On 12/17/25 at 8:46 A.M., the surveyor observed Nurse #1 prepare and administer Resident #62's medication. Nurse #1 prepared one capsule of the probiotic saccharomyces boulardii with the rest of Resident #62's medications and administered it.Review of Physician's Orders indicated but were not limited to the following:-Lactobacillus, give one capsule by mouth two times per day, (dated 9/24/25) Review of the MAR indicated but was not limited to the following:-Lactobacillus was signed off as administered on 12/17/25. During an interview on 12/17/25 at 12:04 P.M., Nurse #1 reviewed the probiotic bottle and said it does not indicate lactobacillus was an ingredient. Nurse #1 said she had administered Resident #62 the wrong probiotic. During an interview on 12/17/25 at 2:23 P.M., the Regional Director of Clinical Operations said physician's orders should be followed, and the correct medications should be administered.

Based on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed. Findings include:Review of the lunch menu for 12/17/25 indicated the residents should have received chicken cacciatore as a main entree. On 12/17/25 at 11:20 A.M., the surveyor observed the lunch tray line and a test tray was conducted. The surveyor along with a second surveyor observed the chicken cacciatore to be red in color and have no sauce or topping. The chicken had a cumin-like flavor. Review of the chicken cacciatore recipe included, but was not limited to, the following ingredients: yellow onions, green peppers, sliced mushrooms, diced tomatoes with juice, oregano, ground thyme, chicken stock, flour, and water. The recipe instructed to mix water and flour and add to boiling chicken and vegetable mixture, stir until thickened. Review of the lunch menu for 12/18/25 indicated residents should have received Harvard beets as a side dish. On 12/18/25 at 11:30 A.M., the surveyor observed the lunch tray line and a test tray was conducted. The surveyor and a second surveyor observed the beets to have no sauce or seasoning with a plain beet taste. Review of the Harvard beets recipe included, but was not limited to, the following ingredients: ground allspice, granulated sugar, cornstarch, and vinegar. During an interview on 12/18/25 at 11:30 A.M., the Food Service Director (FSD) said the food should be prepared according to the recipe in the recipe binder. REFER TO F804

Based on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food for 2 out of 2 test trays conducted. Findings include:During the initial resident screening on 12/16/25, the residents expressed the following concerns about the food at the facility:-Taste of the food is not good; it's overcooked, dry, mushy vegetables;-Food is awful, does not taste good, no flavor;-Flavor is awful, I usually just ask for a peanut butter and jelly sandwich instead of the food;-Food sucks;-Food is not good, poor quality, odd pairings that don't go together;-Food is terrible;-Food is lousy;-Food is gross. On 12/17/25 at 11:20 A.M., the surveyor conducted Test Tray #1 (regular texture). The meal consisted of chicken cacciatore, penne pasta, cauliflower, chilled baked apples, milk, and juice. APPEARANCE: The chicken cacciatore was a red colored chicken thigh with no sauce; the penne pasta was white; and the cauliflower was white. TEXTURE: The cauliflower was overall mushy and could be easily crushed between the tongue and roof of the mouth. FLAVOR: The chicken cacciatore had a subtle cumin-type flavor and was not prepared or served with any sauce. The penne pasta tasted like plain, unseasoned penne pasta. The cauliflower tasted like plain, unseasoned cauliflower. During an interview on 12/17/25 at 11:20 A.M., the Food Service Director (FSD) said the flavor of the meal was subtle and had no concern with the taste or presentation of the test tray. On 12/17/25 at 12:20 P.M., the surveyor observed the meal posting on the 3rd floor had stated chicken cacciatore, penne pasta, and parslied cauliflower. On 12/17/25 at 1:30 P.M., the Resident Council meeting was conducted with 13 residents in attendance. During the meeting the residents collectively expressed the kitchen continues to be problematic, with specific complaints including the following:-Residents disliked the food;-A grievance was submitted that morning requesting the facility to reinstate the selective/alternate menu;-Today's chicken missing the cacciatore part. During an interview on 12/18/25 at 11:53 A.M., the FSD said one of the sides served for yesterday's lunch should have had parsley sprinkled on top. The FSD said food items should be prepared according to the recipe and if there was a change in the menu, then the meal postings on the units would reflect the change and residents would be notified. On 12/18/25 at 12:02 P.M., the surveyor conducted Test Tray #2 (regular texture). The meal consisted of beef tips with gravy, rice, Harvard beets, mandarin oranges with a dollop of whipped cream, milk, and juice. APPEARANCE: The beef tips were extremely tender causing them to lose shape and appear as a mound of beef, unable to fork a shaped beef tip. The beets were cubed and had no sauce, appeared to have been steamed. FLAVOR: The beets tasted like plain beets, no sweet or acidic flavor. The rice tasted like plain rice, unseasoned. The FSD was present for the Test Tray and had no concerns with the appearance or flavor. The results of the test tray and identification of not following the recipes validates the residents' concerns with the food.

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for five Residents (#97, #106, #17, #46, and #6), out of a total sample of 34 residents. Specifically, the facility failed:1. For Resident #97, to:a) ensure medications and treatments were accurately documented during a leave of absence (LOA), and tob) ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 17 of 31 days reviewed; 2. For Resident #106, to ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 16 of 31 days reviewed; 3. For Residents #17 and #46, to ensure volumes of tube feeding and water flushes being administered to the Residents were accurately documented in the Medication Administration Record (MAR); and4. For Resident #6, to accurately document wound care provided on the TAR per the physician's orders. Findings include:Review of the facility's policy titled Charting and Documentation dated as last revised November 2024 indicated but was not limited to the following: -Documentation in the medical record may be electronic, manual, or a combination. -The following information is to be documented in the resident medical record as warranted: objective observations, medications administered, treatments or services performed, changes in the resident condition, events, incidents, or accidents, and progress toward or changes in the care plan goals and objectives. -Documentation in the medical record will be objective, complete, and accurate. 1. Resident #97 was admitted to the facility in April 2025 with diagnoses which include heart disease, abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. Review of the Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated Resident #97 took antiplatelet medication (to prevent blood clots) and hypoglycemic medication (to lower blood sugar) and had undesired/unplanned weight loss of 5% in the last month or 10% in the last six months. a. Review of the medical record indicated Resident #97 had been on a leave of absence (LOA) from approximately 10/17/25 (afternoon/early evening) through 10/19/25 (midday). Review of the Medication Administration Report (MAR) and Treatment Administration Report (TAR) indicated but were not limited to the following: -Friday, 10/17/25 at 8:00 P.M., Medications were signed off as administered. -Friday, 10/17/25 NIGHT SHIFT documented a Temperature of 97.2 with no cold symptoms. -Saturday, 10/18/25 4:30 P.M., Blood Sugar was documented with a reading of 147 and 5:00 P.M., Medications were documented as administered. -Saturday, 10/18/25 NIGHT SHIFT documented a Temperature of 97.4 with no cold symptoms, additionally, Check Placement of Wanderguard on left wrist was documented as completed (+) indicated the wanderguard was on the left wrist. Review of the nursing progress note dated 10/17/25 (LATE ENTRY), indicated This nurse did not witness the residents departure and was not informed during the shift that the resident had left the facility. Therefore, no departure was documented or reported by this nurse at that time. Medication administration prior to departure cannot be confirmed by this nurse. Supervisor notified. During an interview on 12/19/25 at 1:35 P.M., the Wound Nurse said the MAR/TAR should accurately reflect what was administered and/or not administered. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said she was unaware of the specifics surrounding the incident but believes it was determined Resident #97 was out with family and it should have been documented as such. During an interview on 12/19/25 at 4:00 P.M., the Assistant Administrator said it was determined Resident #97 left the building with their son on 10/17/25 in the evening and returned midday on Sunday and the medical record should have reflected that. b. Review of the Meal Percentage Task report for 11/19/25 through 12/18/25 indicated but was not limited to the following: -17 of 31 days reviewed the percentage of lunch consumed was documented prior to meal service being completed. Specifically, the intake was documented between 10:30 A.M. and 12:00 P.M. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said meals should not be documented prior to them being served and consumed. 2. Resident #106 was admitted to the facility in December 2022 with diagnoses which include diabetes mellitus, above the knee amputation, and obesity. Review of the Meal Percentage Task report for 11/19/25 through 12/18/25 indicated but was not limited to the following: -16 of 31 days reviewed the percentage of lunch consumed was documented prior to meal service being completed. Specifically, the intake was documented between 10:30 A.M. and 12:00 P.M. During an interview on 12/18/25 at 10:14 A.M., Unit Manager (UM) #2 said the first lunch truck doesn't leave the kitchen until at least 11:30 A.M. During an interview on 12/19/25 at 12:03 P.M., Nurse #4 said lunch should be documented after they eat not before. During an interview on 12/19/25 at 12:13 P.M., UM #2 said meals should only be documented after they eat. She said these meals were documented prior to lunch and they should not have been. During an interview on 12/19/25 at 12:57 P.M., Certified Nursing Assistant (CNA) #3 said meals should be documented after they eat and before the end of the shift. She said lunch should not be documented before lunch, but honestly the documentation is done when we have time. She said she knows the residents and they usually eat the same amount every day, so sometimes it is documented before lunch. During an interview on 12/19/25 at 1:35 P.M., the Wound Nurse said lunch should only be documented after it is eaten. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said meals should not be documented prior to them being served and consumed. 3A. Resident #17 was admitted to the facility in May 2025 with diagnoses which included brain stem stroke, stage four sacral pressure ulcer, type two diabetes, quadriplegia, locked-in state, and gastrostomy. Review of Resident #17's MDS assessment, dated 12/8/25, indicated the Resident received tube feeding formula via gastrostomy tube feeding (TF) and hydration via TF, which provided the Resident 51% or more of his/her nutrition and hydration from TF and water flushes. The surveyor made the following observations of the Resident's tube feeding and water flushes: 12/16/25 at 3:00 P.M. – Glucerna 1.2 TF formula hung and running at 80mL/hour with total TF value in the tens of thousands indicated on the TF pump; a bag of water for flushes hung at bedside with the pump set to administer 225mL free water every six hours. 12/17/25 at 8:45 A.M. – Glucerna 1.2 TF formula hung and running at 80mL/hour with a total TF value in the tens of thousands indicated on the TF pump; a bag of water for water flushes hung at bedside with the pump set to administer 225mL free water every six hours. 12/17/25 at 2:30 P.M. – Glucerna 1.2 TF formula hung and running at 80mL/hour with total feed equaling 42,861mL; a bag of water for water flushes hung at bedside with pump set to administer 225mL free water every six hours. 12/18/25 at 8:33 A.M. – Glucerna 1.2 TF formula hung and running at 80mL/hour; a bag of water for water flushes hung at bedside with pump set to administer 225mL free water every six hours. Review of Physician's Orders indicated, but was not limited to, the following: -NPO (Latin for nothing by mouth), for tube feeding, 4/22/24; -Enteral Feed Order, every shift, Glucerna 1.2 at 80mL per hour (total volume 1920mL), 5/28/24; -Enteral Feed Order, every shift, Total Intake of formula and water every shift, 5/6/24; -Enteral Feed Order, four times a day, give free water 225mL every 6 hours, 2/27/25. (Of note: 225mL every six hours equals 900mL total) Review of Resident #17's MAR indicated, but was not limited to, the following: December 2025: Enteral Feed Order, every shift, Total Intake of formula and water every shift: 12/1- hospitalized 12/2– Formula 1280mL, water 600mL; 12/3– Formula 1780mL, water 850mL; 12/4, 12/5, 12/6– Formula 1500mL, water 750mL; 12/7– Formula 1400mL, water 750mL; 12/8, 12/9– Formula 1200mL, water 750mL; 12/10, 12/11, 12/12, 12/23, 12/14, 12/15, 12/16– Formula 1470mL, water 450mL; 12/17– Formula 1770mL, water 600mL. Based on the December MAR, Resident #17 received less than the prescribed volume of TF and free water per physician's orders. During an interview on 12/17/25 at 2:54 P.M., Nurse #5 reviewed Resident #17's TF and water flush orders against the MAR and said the MAR values were not accurate; based on the orders the Resident should receive a total of 1920mL of Glucerna 1.2 TF per day and 900mL of water flushes per day. Nurse #5 said the recorded values did not add up to those totals. During an interview on 12/17/25 at 3:20 P.M., Unit Manager #1 said Resident #17 received continuous TF and water flushes and while it's common to hold TF and water flushes to provide care, Resident #17 was bedbound and rarely had his/her TF and water flushes held on a consistent basis or for extended lengths of time unless he/she was being transferred out of the facility or it was warranted to hold them. She said the Resident typically received TF and water flushes during the full 24 hours. Unit Manager #1 reviewed Resident #17's physician's orders for TF and water flush orders against the Resident's December MAR and said the recorded volumes administered did not add up to the total volume. B. Resident #46 was admitted to the facility in October 2024 with diagnoses which included catatonic disorder, diabetes, muscle wasting, and gastrostomy. Review of Resident #46's MDS assessment, dated 10/24/25, indicated the Resident received tube feeding formula via gastrostomy TF and hydration via TF, which provided the Resident with 51% or more of his/her nutrition and hydration from TF and water flushes. The surveyor made the following observations of the Resident's tube feeding and water flushes: 12/16/25 at 8:58 A.M. – Glucerna 1.2 TF hung and running at 70mL per hour with total feed reading of 6822mL. Water bag hanging and set for 150mL every three hours for 17 hours. 12/17/25 at 2:35 P.M. – Glucerna 1.2 TF hung and running at 70mL per hour. Water bag hung and running, set for 150mL every three hours for 17 hours. Review of Physician's Orders indicated, but was not limited to, the following: -NPO, 10/24/24; -Enteral Feed Order, every shift, Glucerna 1.2 at 70mL/hour for 17 hours, up at midnight and down at 5 P.M., total TF of 1190mL per day, 1/24/25; -Water flush, 150mL every 3 hours via pump for 17 hours for total of 750mL, every shift, 1/24/25. Review of the Resident's MAR indicated, but was not limited to the following: December 2025: Enteral Feed Order, every shift, Glucerna 1.2 at 70mL/hour for 17 hours, up at midnight and down at 5 P.M., total TF of 1190mL per day: 12/1 – Formula 1680mL; 12/2 – Formula 1720mL; 12/3 – Formula 860mL; 12/4 through 12/6 – Formula 420mL per day; 12/7 – Formula 360mL; 12/8 – Formula 570mL with evening shift recording the volume as Other; 12/9 – Formula 910mL; 12/10 – Formula 0mL; 12/11 – Formula 280mL with day shift recording 0 volume administered; 12/12 – Formula 420mL; 12/13 through 12/17 – Formula 1680mL per day. Water flush, 150mL every 3 hours via pump for 17 hours daily for a total volume of 750mL: 12/1 – water 440mL; 12/2 – water 450mL; 12/3 – water 500mL; 12/4, 12/5 – water 600mL per day; 12/6 – water 700mL; 12/7 – water 750mL; 12/8 – water 300mL with evening shift recording the volume as Other; 12/9 through 12/16 – water 450mL per day; 12/17 – water 750mL. During an interview on 12/17/25 at 2:54 P.M., Nurse #5 reviewed Resident #46's TF and free water orders against the December MAR and said the MAR values were not accurate. Nurse #5 said the Resident received TF and water flushes for 17 hours per day which included only two hours on the evening shift (3 P.M. to 11 P.M.), yet the MAR indicated the Resident received over 500mL of TF for seven of the 17 evening shifts and that value should be 140mL. Nurse #5 also said the night shift (11 P.M. to 7 A.M.) values should be around 490mL but none of the values were close and seemed to reflect the value of the previous shift. Additionally, Nurse #5 said the total water flush values did not add up to 750mL for 15 of the 17 days in December. During an interview on 12/17/25 at 3:20 P.M., Unit Manager #1 reviewed Resident #46's physician's orders for TF and water flushes against the Resident's December MAR and said the recorded volumes administered did not reflect the physician's orders despite the pumps being programmed appropriately and the Residents receiving the total amounts of TF and water flushes. Unit Manager #1 said staff should be documenting the appropriate values of TF and water flushes being administered. 4. Resident #6 was admitted to the facility in March 2024 with diagnoses which include morbid obesity, Diabetes Mellitus, Peripheral Vascular Disease (PVD), Osteomyelitis of Right Ankle and Foot, and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) Assessment, dated 10/3/25, indicated Resident #6 was at risk for skin breakdown, had a venous/arterial ulcer, an open foot lesion, Moisture Associated Skin Damage (MASD) and had ointments and wound care treatment provided. Review of the Wound Physician progress notes from July 2025 through October 2025 indicated he/she had multiple wounds and was being followed for wound care management. Review of the MAR and TAR from July 2025 through October 2025 indicated but were not limited to the following: JULY 2025: Site: Left Toe: 6 of 31 opportunities treatment not signed off as administered. Site: Groin: 6 of 31 opportunities treatment not signed off as administered. Site: Left Buttock: 4 of 15 opportunities treatment not signed off as administered. Site: Right Lower Leg: 4 of 15 opportunities treatment not signed off as administered. Site: Left Lower Leg: 5 of 16 opportunities treatment not signed off as administered. Site: Scrotum: 14 of 47 opportunities treatment not signed off as administered. Site: Buttocks/Groin: 7 of 31 opportunities treatment not signed off as administered. AUGUST 2025: Site: Left Toe: 5 of 20 opportunities treatment not signed off as administered. Site: Right Lower Leg: 3 of 7 opportunities treatment not signed off as administered. Site: Left Lower Leg: 2 of 16 opportunities treatment not signed off as administered. Site: Scrotum: 10 of 39 opportunities treatment not signed off as administered. Site: Buttocks/Groin: 4 of 20 opportunities treatment not signed off as administered. Site: Right Plantar Foot: 5 of 18 opportunities treatment not signed off as administered. SEPTEMEBER 2025: Site: Left Toe: 7 of 30 opportunities treatment not signed off as administered. Site: Right Lower Leg: 6 of 20 opportunities treatment not signed off as administered. Site: Scrotum: 5 of 60 opportunities treatment not signed off as administered. Site: Buttocks/Groin: 6 of 30 opportunities treatment not signed off as administered. Site: Right Plantar Foot: 6 of 30 opportunities treatment not signed off as administered. OCTOBER 2025: Site: Left Toe: 5 of 31 opportunities treatment not signed off as administered. Site: Left Buttock: 2 of 15 opportunities treatment not signed off as administered. Site: Right Lower Leg: 1 of 1 opportunities treatment not signed off as administered. Site: Left Lower Leg: 2 of 15 opportunities treatment not signed off as administered. Site: Scrotum: 6 of 62 opportunities treatment not signed off as administered. Site: Buttocks/Groin: 3 of 31 opportunities treatment not signed off as administered. Site: Right Plantar Foot: 2 of 22 opportunities treatment not signed off as administered. Site: Sacrum: 1 of 13 opportunities treatment not signed off as administered. Review of the medical record failed to indicate why the above treatments were not administered as ordered. During an interview on 12/19/25 at 12:13 P.M., Unit Manager #2 said treatments should be done per the physician's orders. During an interview on 12/19/25 at 1:35 P.M., the Wound Nurse said treatments should be done per the orders, there should not be blanks on the TAR. She said sometimes they refuse care but that should be coded as refused and not left blank if that is the case. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said Resident #6 is followed by the wound care team and expects all treatments to be done per the physician's orders and signed off. She said there should not be blanks on the TARs. She said if they refused care, it should be documented as refused.

Based on observations and interviews, the facility failed to adhere to infection prevention and control standards of practice to prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1a. Ensure that sanitary practices were used by nursing while preparing and administering medications,b. Clean and disinfect shared equipment before and/or after use; and 2. [NAME] (put on) gloves prior to obtaining Resident #3's blood sugar. Findings include: Review of the facility's policy titled Administering Medications, dated as revised September 2024, indicated but was not limited to:-Staff follows established facility infection control procedures for the administration of medications, as applicable. Review of the facility's policy titled Infection Control Guidelines for Nursing Procedures, dated as revised July 2024, indicated but was not limited to:-Standard precautions are the minimum infection prevention practices that apply to all resident care. These practices are designed to both protect the health care provider and prevent the health care provider from spreading infections among residents. Standard precautions include: hand hygiene and sharps safety.-The nurse should clean multi-use equipment between resident use with the appropriate cleaning solution based on manufacturer's guidelines. 1. On 12/17/25 at 8:46 A.M., the surveyor observed Nurse #1 prepare and administer Resident #62 his/her medications as follows:a. -Nurse #1 prepared an over-the counter-medication and poured two tablets into the cap of the medication bottle. -Nurse #1 used an ungloved finger to secure one tablet to the top of the cap and attempted to drop the other tablet into the medication cup. -Nurse #1 dropped both tablets into the medication cup and then used a spoon to scoop one of the tablets out and put it back into the bottle. -Nurse #1 returned the medication bottle into the top drawer of her medication cart. -Nurse #1 administered the other tablet to Resident #62. b. -Nurse #1 removed the facility glucometer from her medication cart and brought it into Resident #62's room.-Nurse #1 used the glucometer to obtain his/her blood sugar. -After obtaining the blood sugar she placed the glucometer on Resident #62's overbed table. -Upon completion of medication administration, Nurse #1 exited the Resident's room and placed the glucometer on top of her medication cart and then into her medication cart. -Nurse #1 failed to sanitize the glucometer before and after use and returned the potentially contaminated glucometer to the medication cart. 2. On 12/17/25 at 11:54 A.M., the surveyor observed the following:- Nurse #1 remove the glucometer from the top of her medication cart and walk into the unit dining room.- Nurse #1, with ungloved hands, obtained Resident #3's blood sugar.-Nurse #1 returned to the medication cart and placed the glucometer on the top of her medication cart.-Nurse #1 failed to sanitize the glucometer after use and returned the potentially contaminated glucometer to the medication cart. During an interview on 12/17/25 at 12:04 P.M., Nurse #1 said medications should not be touched with ungloved hands. She said glucometers should be cleaned after every use and gloves should have been worn to check Resident #3's blood sugar. During an interview on 12/17/25 at 2:23 P.M., the Regional Director of Clinical Operations said infection control practices should be followed. She said medications should not be touched with ungloved hands, and shared equipment should be cleaned after use and gloves should be worn when obtaining a blood sugar.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#4), out of a total sample of 34 residents. Specifically, the facility failed to implement physician's orders for Foley catheter (medical device used to drain urine from the bladder) care. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #4 was admitted to the facility in September 2024 with diagnoses including dementia, Parkinson's disease, urinary tract infection (UTI), and obstructive and reflux uropathy. Review of Resident #4's medical record indicated he/she had a hospital admission from 11/23/25 through 11/30/25 due to altered mental status. Resident #4 was re-admitted to the facility on [DATE]. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 12/6/25, indicated he/she had an indwelling catheter and was always incontinent. Review of Resident #4's Hospital Discharge summary, dated [DATE], indicated but was not limited to the following:- Resident #4 was diagnosed with a UTI during hospitalization.- Urology recommended to discharge the Resident with a Foley catheter with a voiding trial in the community. Review of Resident #4's Physician's Orders indicated but were not limited to the following:- 12/4/25 through 12/9/25: Foley catheter care, every shift- 12/4/25 through 12/9/25: may irrigate Foley catheter with 50cc (cubic centimeter) of normal saline for sediment or blockage- 12/6/25: DC (discharge) Foley catheter Review of Resident #4's medical record indicated he/she had a Foley catheter on re-admission to the facility on [DATE] and it was discharged on 12/6/25 following review by the Nurse Practitioner. Review of Resident #4's December 2025 Treatment Administration Record (TAR) indicated the facility failed to provide 11 Foley catheter care treatments between 12/1/25 through 12/4/25. During an interview on 12/19/25 at 12:55 P.M., Unit Manager (UM) #2 said Resident #4 had recently been hospitalized and returned to the facility with a Foley catheter. UM #2 said Foley catheter care orders should have been implemented on admission and not delayed until 12/4/25. During an interview on 12/19/25 at 1:03 P.M., the Director of Nursing (DON) said any resident admitted to the facility with a Foley catheter should have orders implemented for its care. The DON and the surveyor reviewed the findings from Resident #4's TAR. The DON said orders should have been implemented for Foley catheter care when Resident #4 was re-admitted to the facility.

Based on interview and record review, the facility failed to notify the Physician (MD)/ Nurse Practitioner (NP) or Resident Representative of an 11.29% significant weight loss in six months for one Resident (#97), out of a total sample of 34 residents. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, dated as last revised July 2024, indicated but was not limited to the following:-The nurse will notify the resident's provider or on call provider when there has been a change in resident condition, including a significant change in resident's physical condition.-The nurse/designee shall notify the resident's representative when there is a significant change in the resident's condition.-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Resident #97 was admitted to the facility in April 2025 with diagnoses which include abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. Review of the Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated Resident #97 had undesired/unplanned weight loss of 5% in the last month or 10% in the last six months. Review of the Comprehensive Care Plan indicated but was not limited to the following:FOCUS: NUTRITION: Resident is at nutritional risk.GOAL: The resident will have no significant changes in weight through review date.INTERVENTIONS: Monitor/Record weights per facility protocol/MD orders; Diet Consult as needed. Review of the Physician's Orders indicated his/her diet was Heart Healthy, CCHO (Controlled Carbohydrate for diabetic management). No nutritional supplements were ordered. Review of the Weight Summary for Resident #97 indicated but was not limited to the following:-4/9/25: 124 pounds (lbs.)-5/7/25: 118 lbs.-6/4/25: 118 lbs.-7/11/25: 117 lbs.-8/7/25: 115 lbs.-9/3/25: 115 lbs.-10/8/25: 110 lbs. Resident #97's weight was down 11.29% in six months (April to October). Review of the Nursing, MD, and NP progress notes failed to indicate the resident representative, MD/NP were notified of the significant weight loss and failed to indicate the weight loss had been addressed since it had been identified on 10/8/25 (72 days). During an interview on 12/19/25 at 12:03 P.M., Nurse #4 said she was not sure of the facility policy on weights and notifications. During an interview on 12/19/25 at 12:13 P.M., Unit Manager #2 said the MD/NP and resident representative should be notified of significant weight loss. During an interview on 12/19/25 at 1:35 P.M., the Wound Nurse said the resident representative, MD/NP should all be notified if a significant weight loss was identified, and he/she would be evaluated for additional interventions within a week by the RD and/or MD/NP. During an interview on 12/19/25 at 2:29 P.M., the Regional Director of Clinical Operations said when weight loss is identified the resident representative, MD/NP should all be notified and weight loss addressed and she did not see in the record that that occurred.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in three of four nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). Findings include:1. Review of the facility's policy titled Food Brought into Facility, revised 4/2019, indicated but was not limited to the following:- It is the policy of the Company that visitors or family members are permitted to bring food to a resident and are encouraged to limit foods to those that meet patient's meal plan and safe food handling practices.- Visitors and family members should take all food to the nurse's station before it is provided to the resident.- Perishable foods must be stored and identified with resident's name, food item and use by date.- Nursing staff is responsible for discarding perishable foods on or before the use by date. On 7/22/25 at 11:44 A.M., the surveyor made the following observations in the River 2 Kitchenette:- The inside of the microwave had orange/brown residue and food splatter covering the tops and sides.- A white plastic bag containing a loaf of bread was labeled only with a resident name and had no use by date. On 7/22/25 at 12:05 P.M., the surveyor made the following observations in the [NAME] 2 Kitchenette:- The inside of the microwave had orange/brown residue and food splatter covering the tops and sides.- The refrigerator contained two clear plastic containers with food product, labeled with a resident name but no use by date. There were visible moisture/water droplets inside each of the containers.- The refrigerator contained one clear plastic container with a small salad, labeled with a resident name and a use by date of 7/20/25. There were moisture/water droplets inside of the container. The lettuce and vegetables were noted to be browning.- The bottom right drawer of the refrigerator had a bag of red [NAME] apples and a container of red grapes. Both items were not labeled with any resident identification or use by dates. On 7/22/25 at 12:47 P.M., the surveyor made the following observations in the River 1 Kitchenette:- The inside of the microwave had a gray residue covering the top/sides.- A white plastic bag was inside the freezer containing five individual ice cream cups (in plastic cups) with no lids as well as three Bizcocho cakes. Neither the bag nor the individual ice cream cups/cakes were labeled with resident identification or a use by date. The ice cream cups were freezer burned with discoloration to the top. On 7/23/25 at 11:11 A.M., the surveyor made the following observations in the River 2 Kitchenette:- The inside of the microwave had orange/brown residue and food splatter covering the tops and sides.- A white plastic bag containing a loaf of bread was labeled only with a resident name and had no use by date. On 7/23/25 at 11:15 A.M., the surveyor made the following observations in the [NAME] 2 Kitchenette:- The inside of the microwave had orange/brown residue and food splatter covering the tops and sides.- The bottom right drawer of the refrigerator had a bag of red [NAME] apples and a container of red grapes. Both items were not labeled with any resident identification or use by dates. On 7/23/25 at 11:21 A.M., the surveyor made the following observations in the River 1 Kitchenette:- The inside of the microwave had a gray residue covering the top/sides.- A white plastic bag was inside the freezer containing five individual ice cream cups (in plastic cups) with no lids as well as three Bizcocho cakes. Neither the bag nor the individual ice cream cups/cakes were labeled with resident identification or a use by date. The ice cream cups had freezer burn and discoloration to the top.During an interview on 7/24/25 at 1:20 P.M., the Food Service Director (FSD) said dietary staff are responsible for stocking unit refrigerators and ensuring items in the refrigerators and freezers are properly labeled and dated. The FSD said the dietary staff are also responsible for making sure the microwaves and refrigerators/freezers are clean. The FSD and the surveyor reviewed the observations made in the unit kitchenettes throughout the survey. The FSD said all items should have proper labels including resident identification and use by dates. The FSD said microwaves, refrigerators and freezers should be clean from any food residue or spills.2. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 7/24/25 at 11:00 A.M., the surveyor made the following observations of the lunch line service:- 11:00 A.M. to 11:15 A.M.: [NAME] #1 was taking the temperature of the food products on the service line and in the refrigerator. [NAME] #1 used an alcohol wipe to clean the thermometer between food products and dispose of the alcohol wipe in a trash can in the kitchen. [NAME] #1 touched the top of the trash can and/or lid when disposing of the alcohol wipes and then returned to obtaining temperatures of food products without washing her hands.- 11:22 A.M.: Dietary Aide #1 dropped three bags of potato chips on the ground. With his gloves donned (on), Dietary Aide #1 grabbed the bags off the ground and placed them in a box above the food service line. Dietary Aide #1 continued to work on the food service line and was not observed to change his gloves.- 11:28 A.M.: [NAME] #1, with gloves donned, left the food service line to grab a package of hamburger buns from across the kitchen. [NAME] #1 opened the package and plated the hamburger bun. [NAME] #1 was then observed to be working on the stove top as well as grabbing items out of the oven including a hamburger patty which was placed on the bun. [NAME] #1 was not observed to change her gloves.- 11:34 A.M.: Dietary Aide #1 left the kitchen with gloves donned to deliver a meal truck to the unit.- 11:39 A.M.: Dietary Aide #1 returned to the kitchen from delivering a meal truck to a unit still wearing his gloves. Dietary Aide #1 then returned to the food service line and plated food items without changing his gloves.- 11:48 A.M.: Dietary Aide #1 grabbed food covers off a rack on the food service line, touching the food covers to his shirt and body prior to placing the lids on the tray containing resident food.During an interview on 7/24/25 at 1:25 P.M., the FSD said dietary staff should be washing their hands and changing gloves when breaking from a task on the service line or leaving the kitchen. The FSD said [NAME] #1 should have washed her hands in between obtaining food product temperatures if she touched the trash can and/or lid. The FSD said Dietary Aide #1 should have washed his hands and changed gloves after picking up items from the ground and returning from delivering meal trucks to the unit. The FSD said food covers should not touch a staff member's clothing or body prior to being placed on a meal tray.

Based on observation, record review, and interview, the facility failed to ensure the standard of nursing practice was followed for one Resident (#55), out of a total sample of 31 residents. Specifically, the facility failed to ensure physician's orders for bolus tube feedings (TF) were administered by nursing as written and the Resident was assessed for competency to self-administer his/her own bolus tube feeding (TF) and had a physician's order to do so. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.Review of the facility's policy titled Self-Administration of Medications, dated as revised 9/2024, indicated but was not limited to the following: Residents have the right to self-administer if the interdisciplinary team has determined it is clinically appropriate and safe for them to do sofollowing an evaluation the staff will document their findings Resident #55 was admitted to the facility in July 2025 with diagnoses including: malignant neoplasm of the mandible, mouth, pharynx and overlapping sites; dysphagia (difficulty swallowing); gastrostomy status (presence of a surgically created opening with a tube into the stomach for the purpose of nutrition- G-tube).Review of the Brief Interview for Mental Status score, dated 7/16/25, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the current orders for Resident #55, as of 7/23/25, indicated but were not limited to the following: Regular diet, easy to chew texture, thin liquid consistency (7/16/25)Enteral Feed order: Jevity 1.5 calories, 500 milliliters (mls) bolus three times a day, may hold if eats greater than 50% of by mouth meals (7/19/25)Enteral Feed order: Give 200 mls free water four times a day (7/16/25)During an interview on 7/22/25 at 12:45 P.M., the surveyor observed Resident #55's room. In front of their bureau there were numerous TF supplies including: one sealed 237ml box of Jevity 1.5cal, 3 small bottles of sterile water, 2 piston syringes, a notebook, and a large 1500 ml bottle of Jevity 1.5ml that was sealed. Resident #55 said he/she provides him/herself with bolus feedings of Jevity about three times a day. Resident #55 said he/she is concerned that the facility may run out of the small individual boxes (containing 237 mls each) and he/she may have to try to use a large bottle (containing 1500 mls) which he/she is unsure if he/she can manage that independently. Resident #55 said he/she had just provided him/herself a bolus about 20 minutes prior and showed the surveyor their G-tube. The surveyor observed the G-tube to have what appeared to be residual tube feeding in the tube from insertion to the clamp. The Resident said he/she keeps a notebook record of when he/she provides him/herself the bolus, how much he/she takes and at what time, but said he/she does not consistently take the bolus three times a day or more than one 237 ml box at one time. Review of the progress notes for Resident #55 indicated but were not limited to the following: 7/16/25: Physician progress note: Concerns with G-tube dysfunction, G-tube in place and Jevity 1.5 - 500ml three times a day ordered and tolerated plus free water flushes. Plan: G-tube care, continue feeds and monitor tolerance7/19/25: G-tube patent and pt does feeds and flushes on own7/23/25: G-tube is patent and pt independent with water flushes and bolus feedings if by mouth intake is not adequateFurther review of the medical record failed to indicate an order for the Resident to self-administer their tube feeding or flushes or an evaluation to determine if the Resident was capable or could demonstrate the ability to provide themselves G-tube feedings and flushes as ordered in the progress notes, or a resident education evaluation or self-administration evaluation.Review of the Resident #55's personal notebook of GT feedings indicated but was not limited to the following: 7/17/25: took 1 (237ml box) three times7/18/25: took 1 box in the A.M., two boxes in the afternoon, and an unknown amount from a large bottle in the evening7/19/25: took 2 boxes in the morning and afternoon, but couldn't finish 2 boxes in the evening having taken an unknown amount7/20/25: took 2 boxes in the A.M., took one in the afternoon and two in the evening7/21/25: took 2 boxes in the A.M. and afternoon and an unknown amount in the evening due to not turning on the lights7/22/25: took 2 boxes in the A.M. and afternoon and one in the eveningReview of the July 2025 Medication Administration Record (MAR) indicated but was not limited to the following: Jevity 1.5cal 500 ml bolus three times a day, may hold if eats >50% of by mouth meals: was signed off as administered by the nurse and received by the Resident 18 of 20 opportunities (with one refusal and one other)Review of the intake percentage of meals for Resident #55 indicated 51% or greater was consumed by mouth by the Resident 14 out of 17 opportunities.During an interview on 7/23/25 at 9:57 A.M., Nurse #2 said Resident #55 is independent with providing him/herself with their G-tube feedings three times a day. She said she does sign off on the MAR that the feeding was administered after asking the Resident if they gave themself a bolus. She said she does not ask how much the Resident provided to themself since the order is 500 ml. She said upon reading the orders for Resident #55 there is no order for the Resident to self-administer their own tube feedings and the MAR actually reads as if the nurse is administering the feed herself and she is not. She said she does not believe anyone has ever observed or evaluated the Resident to determine if they were capable of physically following the MD order for the G-tube feedings and assumed they were since they came from an assisted living. She reviewed the medical record and said she could not find any evidence that the physician provided an order for the Resident to self-administer or that the Resident was educated or evaluated for self-administration of his/her G-tube feedings and all that should be in place. During an interview on 7/23/25 at 11:20 A.M., the Dietitian said he evaluated the Resident for nutritional and hydration needs. He said he went in to see the Resident either 7/22 or 7/21 and caught the Resident providing themself their bolus feeding through their G-tube. He said he reported this to a nurse and was told the Resident was independently providing themselves the bolus feedings. He said he did not evaluate whether or not the Resident was doing the bolus feedings correctly or if the MD was aware and that there was an order in place since that is not within the scope of his practice and that is why he reported it to the nurses. He said he would assume if the nurses are aware the Resident is providing themselves their bolus feeds, then the nurses are monitoring the amounts to ensure the ordered and necessary calculated amounts are being provided each time.During an interview on 7/23/25 at 11:44 A.M., Unit Manager #4 said the unit has not had a resident that self-administers anything in quite a while but the process is for the Licensed nurse to determine if the resident is competent to do so, then if they are obtain an MD order for self-administration and document on the MAR that the resident verbally confirms administration. She reviewed the medical record and said even though there are two self-administration evaluations and a resident education evaluation there is no evidence that anyone had ever evaluated Resident #55 to determine if he/she was capable of self-administering their G-tube bolus or even knew what the order was for their bolus feedings. She said in addition there is no physician order for the Resident to self-administer and therefore the Licensed nurses should be administering the bolus feeding and documenting them on the MAR to ensure all 500 ml are received when necessary and documenting any discrepancies. She said the process was not followed for this Resident to be able to self-administer his/her own G-tube feedings in accordance with the current physician's orders. During an interview on 7/24/25 at 12:27 P.M., the Director of Nurses and Director of Clinical Operations said Resident #55 should have MD orders to self-administer their G-tube feedings and be evaluated for competency of that task and the expectations are that the Licensed nurses are following MD orders as written, and in this instance those things did not occur. During an interview on 7/24/25 at 1:54 P.M., the Attending Physician for Resident #55 said the Resident had a history of G-tube dysfunction meaning multiple blockages in the past. He said he did not provide any orders for this Resident to self-administer their own G-tube feedings and was not aware that was occurring at the time the Resident was evaluated or admitted to the facility. He said his expectation is that when he writes an order, like the one for this Resident to receive bolus feedings, and that the Licensed nurses are providing that to the Resident and in the amount ordered and documenting any deviation and notifying him. He said he was made aware of this not occurring as it should have by the facility on 7/23/25, after the survey team brought the concern to the facility's attention.

Based on observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#155), out of 31 sampled residents, to address the Resident's hearing loss.Findings include:Review of the facility's policy titled Ancillary Physician Services, last revised March 2025, indicated routine Audiology services were available to meet the resident's health needs. The policy indicated the services could be available through a contract agreement with an Audiologist that comes to the facility, or referral to community Audiologists. Resident #155 was admitted to the facility in May 2024 with a diagnosis of hearing loss. Review of the Minimum Data Set (MDS) assessment indicated the following for Resident #155:5/22/24: moderate difficulty with hearing; no hearing aid or other hearing appliance9/5/24: moderate difficulty with hearing; no hearing aid or other hearing appliance12/4/24: highly impaired hearing; no hearing aid or other hearing appliance5/23/25: highly impaired hearing; no hearing aid or other hearing appliance; Brief Interview for Mental Status score 10 out of 15, indicating the Resident had a moderate cognitive impairment. During an interview on 7/22/25 at 9:05 A.M., Resident #155 said he/she could not hear the surveyor, and their left ear was better than the right ear. Review of a care plan, initiated on 5/16/24, indicated Resident #155 had a communication problem related to moderate hearing impairment and deficits in understanding and making self understood with a goal of being able to communicate simple concrete needs. The interventions included: discuss with resident/family concerns or feelings regarding communication difficulty, allow time to respond and a new intervention on 7/2/25 for ear drops every night for five days. Review of the active Physician's Orders for Resident #155 indicated to consult Audiology as needed. During an interview on 7/24/25 at 1:17 P.M., the Health Care Proxy (HCP) of Resident #155 said the Resident had increased difficulty hearing over the last year. He said he had attended a care plan meeting the previous month where they had discussed the increased hearing loss. He said he was not sure if the Resident had ever seen an Audiologist, but believed the facility was working on it. Review of the Care Plan Meeting notes, dated 6/12/25, failed to indicate any information regarding the HCP's request for assistance with the Resident's hearing. Review of the nursing progress notes indicated on 7/2/25 Resident #155 complained he/she could not hear out of their right ear; the right ear was noted with wax build-up and an order for ear drops was obtained. During an interview on 7/23/25 at 11:26 A.M., Nurse #5 said Resident #155 had received the five days of ear drops to the right ear, following a flush on the sixth day. The Nurse said the ear flush was successful, and the Resident cannot hear at baseline. The Nurse said every day the Resident will say he/she cannot hear. During an interview on 7/24/25 at 1:43 P.M., Unit Manager #3 said the Audiologist was at the facility in June 2025 and Resident #155 was not on the list of residents who were seen. She said she started working at the facility at the end of June 2025 and was not aware Resident #155 could not hear at baseline. During an interview on 7/25/25 at 8:46 A.M., the Medical Records staff said Resident #155's consent for ancillary services was sent over to the consultant ancillary service company on 6/6/25. She said she had sent the consent form for Resident #155 so the Resident could be seen by the dentist. She said she had not requested for Resident #155 to be seen by the consultant Audiologist. She said she had never been asked to have Resident #155 be seen by an Audiologist. She said the consultant Audiologist visits the facility approximately every quarter and was at the facility on 6/16/25 and did not see Resident #155. During an interview on 7/25/25 at 9:00 A.M., the Director of Clinical Operations said the Unit Manager and the Social Worker who attended the care plan meeting for Resident #155 on 6/12/25 no longer worked at the facility. She said she could not speak to why the Resident had not been referred to Audiology services.

Based on interview and record review, the facility failed to ensure the state agency responsible for Preadmission Screening and Resident Review (PASRR) was notified following psychiatric hospital admissions for one Resident (#155), in a total sample of 31 residents.Findings include:Review of Nursing Facility Bulletin 186: Updates to Nursing Facility Regulations: Preadmission Screening and Resident Review (PASRR) for Intellectual Disability, Developmental Disability, and Serious Mental Illness (SMI) indicated the following:-PASRR Portal: An online portal that is required for the submission of all Level I Screening forms -A nursing facility must ensure an individual who has or is suspected of having SMI is referred to the state PASRR Unit, for a post-admission Level II Evaluation (i.e. a Resident Review) in the following instances: When an individual who resides in a nursing facility has experienced a Significant Change; including but not limited to: The resident is transferred, admitted , or readmitted to a nursing facility following an inpatient psychiatric stay or equally intensive treatment. Resident #155 was admitted to the facility in May 2024 with diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder. Review of the medical record indicated Resident #155 was admitted to psychiatric hospitals in August 2024 and March 2025. Review of the medical record indicated the most recent PASRR was dated 7/12/24, prior to the psychiatric hospital admissions. During an interview on 7/23/25 at 12:05 P.M., Social Worker #1 said he checked the PASRR portal and the last PASRR submitted for Resident #155 was in July 2024. He said there were no additional PASRRs submitted for the Resident. He said he can see in the medical record that Resident #155 had psychiatric admissions in August 2024 and March 2025. He said a Resident Review should have been submitted in the PASRR portal following the psychiatric admissions.

Based on interviews and records reviewed, the facility failed to ensure one Resident (#6), out of a total sample of 31 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #6, to implement treatments from the wound consultant physician for a chronic Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the ischium (lower buttocks). Findings include: Resident #6 was admitted to the facility in August 2023 with a chronic stage 4 pressure ulcer on the ischium. Review of the care plans indicated Resident #6 had a stage 4 pressure ulcer and could be non-compliant with offloading (not bearing weight on an area) and dietary recommendations with a goal to improve skin integrity by signs and symptoms of healing. The care plan interventions included but were not limited to: consult and treatment by wound physician; follow orders for skin care and treatments. Review of the Consultant Wound Physician Encounter Form, dated 6/17/25, indicated Resident #6's Stage 4 pressure ulcer measured 3.7 centimeters (cm) in length, by 3.0 cm in width, by 0.2 cm in depth and had a large amount of serous exudate (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage). The following treatment plan was indicated: antibacterial wound cleanser, Alginate (made of fibers that absorb wound fluid and promote healing), and followed by foam to the left ischium wound twice daily and as needed. Review of the June 2025 Treatment Administration Record (TAR) indicated this treatment was completed as ordered, twice daily. Review of the Consultant Wound Physician Encounter Form, dated 7/1/25, indicated Resident #6's Stage 4 pressure ulcer measured 4.0 cm in length by 3.5 cm in width by 0.4 cm in depth and had a moderate amount of serous exudate. The following treatment plan was indicated: Primsa/Puracol/Dermacol (or similar collagen dressing (a dressing with the collagen protein, used to promote healing), Alginate, and followed by foam to the left ischium once daily. Review of the nursing progress, dated 7/1/25 and written by Nurse #9, indicated Resident #6 was seen by the Consultant Wound Physician with a treatment of antibacterial wound cleanser, pat dry, apply collagen dressing and foam to the left buttock daily. Review of the Physician's Orders and July 2025 TAR on 7/23/25 failed to indicate the treatment had been updated to include the collagen dressing. Review of the Consultant Wound Physician Encounter Form, dated 7/15/25, indicated Resident #6's Stage 4 pressure ulcer measured 3.7 cm in length by 3.5 cm in width by 0.2 cm in depth and had a moderate amount of serous exudate. The following treatment plan was indicated: Primsa/Puracol/Dermacol (or similar collagen dressing (a dressing with the collagen protein, used to promote healing), Alginate, and followed by foam to the left ischium once daily. Review of the nursing progress, dated 7/16/25 and written by the Assistant Director of Nurses (ADON), indicated Resident #6 was seen by the Consultant Wound Physician with a treatment of antibacterial wound cleanser, pat dry, apply collagen dressing and foam to the left buttock daily. During an interview on 7/24/25 at 2:05 P.M., Nurse #4 said she had completed the dressing change for Resident #6 that morning. She said the treatment she completed was for the antibacterial wash, followed by Alginate, followed by a foam dressing. During an interview on 7/25/25 at 10:53 A.M., Nurse #6 said she had completed the dressing change for Resident #6 that morning. She said the treatment she provided was for antibacterial wash, followed by Alginate, followed by a foam dressing and demonstrated the products to the surveyor. During an interview on 7/25/25 at 11:27 A.M., Nurse Practitioner #1 said the in-house Consultant Wound Physician saw residents weekly and determined the treatments needed for managing the wounds. She said the facility defers to the Consultant Wound Physician on wound treatment orders. During an interview on 7/25/25 at 11:35 A.M., Nurse #9 said she was previously the ADON at the facility and that was why she was conducting weekly wound rounds. She said she had conducted wound rounds with the Consultant Wound Physician on 7/1/25. She said the process was that at the end of the visit the Consultant Wound Physician provides a copy of the Encounter Form and the ADON will document in a progress note and make changes to the treatment orders. She reviewed the medical record with the surveyor and said the changes to the treatment on 7/1/25 were not made in the electronic medical record and did not reflect the accurate order from the Consultant Wound Physician.

Based on record review and interview, the facility failed to ensure the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of the benefits, risks, and alternatives for the medication prior to providing psychotropic medication for one Resident (#3), out of 31 sampled residents.Findings include:Review of the facility's policy titled Psychotropic Medication, dated as revised 7/2023, indicated but was not limited to:-A written informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medicationResident #3 was admitted to the facility in October 2024 with diagnoses that include dementia and depression.Review of the Minimum Data Set (MDS) assessment, dated 6/27/25, indicated Resident #3 received antidepressant medication.Review of Resident #3's Physician's Orders indicated but were not limited to:-invoked HCP, dated 10/30/24-Sertraline (antidepressant) 25 milligrams (mg) by mouth daily, dated 6/22/25Review of Resident #3's June and July 2025 Medication Administration Record (MAR) indicated he/she received Sertraline as ordered.Review of Resident #3's electronic and paper records failed to indicate his/her representative was notified of the benefits, risks, and alternatives of Sertraline.During an interview on 7/28/25 at 3:12 P.M., Nurse #7 said before a psychotropic medication is started the resident or resident representative must be notified of the risks, benefits and side effects. Nurse #7 said the facility completes a consent form indicating the notification had occurred.During an interview on 7/28/25 at 3:08 P.M., Unit Manager #3 said the initiation of psychotropic medication requires consent from the resident or his/her representative, as indicated. Unit Manager #3 said the resident/resident representative should be aware of the benefits, risks, and alternative options prior to initiation of the medication. Unit Manager #3 said to indicate acceptance, the facility completes a consent form that is signed by the resident/resident representative. Unit Manager #3 reviewed Resident #3's medical record and could not locate a consent form. Unit Manager #3 said Resident #3 was not his/her own person and their HCP had been activated and should have signed a consent for Sertraline prior to it being initiated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, frequently incontinent and dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was free from verbal abuse by staff members when, during the night shift (11:00 P.M. to 7:00 A.M.) on 03/09/25, Certified Nurse Aide (CNA) #1 and CNA #2 yelled at, made insulting and ridiculing comments to Resident #1, who said he/she was upset, humiliated and cried after the incident. Findings include: Review of the Facility Policy titled Abuse Investigation and Reporting, last revised February 2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse. Review of the Facility Policy titled Resident Rights, last revised January 2024, indicated employees shall treat all residents with kindness, respect and dignity. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 3/12/25, indicated that Resident #1 reported that Certified Nurse Aide (CNA) #1 and CNA #2 verbally abused him/her. Review of the Facility's Internal Investigation Report, undated, indicated that on 3/12/25, Resident #1 reported that at 2:00 A.M. on 3/09/25, he/she had diarrhea and CNAs (later identified as CNA #1 and CNA #2) yelled at him/her, said that he/she could have prevented the diarrhea and incontinence and said that he/she was lazy. Resident #1 was admitted to the Facility during October 2017 and his/her diagnoses included anxiety disorder, depression, and post-traumatic stress disorder. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated his/her cognitive patterns were intact, he/she was frequently incontinent of bowel and bladder and he/she required assistance with hygiene and bathing. Resident #1's Care Plan regarding Self-Care Deficit, dated as revised 2/23/25, indicated interventions which included total dependence on staff members for showers and personal hygiene and the assistance of two staff members with toileting needs. During an interview on 3/31/25 at 10:00 A.M., the Unit Manager said that on 3/12/25, Resident #1 reported that on 3/09/25 CNAs #1 and #2 yelled at him/her after he/she was incontinent in bed. The Unit Manager said that Resident #1 told her that CNAs #1 and #2 weren't very nice to him/her and had told him/her that he/she was lazy and should have gotten up to use the bathroom. During an interview on 3/31/25 at 10:25 A.M. Resident #1 said on 3/09/25 during the overnight shift, around 2:00 A.M., two CNA's came to his/her room to provide care, that it was dark but that he/she knew who the CNA's were by their voices, and said their names (identifying CNA #1 and CNA #2). Resident #1 said after finding he/she had been incontinent in the bed, that both CNA #1 and CNA #2 were verbally abusive to him/her. Resident #1 said CNA #1 and #2 told him/her to get his/her ass out of bed and get to the shower. Resident #1 said that CNA #1 and #2, without first helping to clean him/her up or remove his/her feces covered Johnny, told him/her to walk to the shower, and that he/she continued to be incontinent of diarrhea while walking to the shower. Resident #1 said that once in the shower room, CNA #1 and #2 told him/her to stop acting like an animal and, when he/she was incontinent again during the shower, he/she heard them say he/she's doing it again, shitting like a cow. Resident #1 said that he/she felt verbally abused, was humiliated and upset as a result of the incident, and that the CNA's treatment of him/her that night made him/her cry. Review of Resident #2's Minimum Data Set (MDS) assessment, dated 1/10/25, indicated he/she had a BIMS score of 15/15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, 13-15 suggests cognition intact. The MDS indicated Resident #2 was alert, oriented, able to make self understood and understood others. During an interview on 3/31/25 at 10:35 A.M., Resident #2, who shared a room with Resident #1, said that during the overnight shift on 3/09/25, he/she heard CNA #1 and #2 yell at Resident #1. Resident #2 said that CNA #1 and #2 yelled oh my God and what a mess when they found that Resident #1 had moved his/her bowels in bed. Resident #2 said CNA #1 and #2 made Resident #1 walk to the shower in a [NAME] which was soiled by feces and that he/she heard them yell at Resident #1 the whole way to the shower. Resident #2 said he/she heard CNA #1 and #2 say to Resident #1 that he/she wouldn't have been incontinent in his/her bed if he/she wasn't so lazy and if he/she didn't eat the foods that he/she ate. Resident #2 said that Resident #1 cried and apologized to CNA #1 and #2 for having been incontinent in the bed. Resident #2 said that he/she heard CNA #1 and CNA #2 tell Resident #1 that he/she ought to be sorry and he/she should stop acting like an animal. During a telephone interview on 4/01/25 at 2:50 P.M., CNA #1 said that she and CNA #2 assisted Resident #1 following an incident in which Resident #1 was incontinent of stool in bed. CNA #1 said on 3/09/25, she assisted CNA #2 that night, while they provided care to Resident #1, that CNA #2 yelled at Resident #1 and made insulting and ridiculing comments. CNA #1 said that CNA #2 asked Resident #1 why he/she hadn't called to use the bathroom and said that Resident #1 was fucking ridiculous and fucking disgusting. CNA #1 said however, that she did not know whether CNA #2 was calling Resident #1 ridiculous and disgusting or was talking about the condition of his/her bed. CNA #1 said that CNA #2 told her, while in Resident #1's presence and where he/she could hear, that Resident #1 was with it and had moved his/her bowels in bed on purpose. CNA #1 said that while CNA #2 walked Resident #1 to the shower room, CNA #2 muttered that Resident #1 was shitting like a cow. CNA #1 said that once Resident #1 was in the shower, CNA #2 continued to run her mouth and use foul language when Resident #1 had been incontinent of stool during the shower. CNA #1 said that she was present when CNA #2 yelled at and made insulting and ridiculing comments toward Resident #1. CNA #1 denied that she yelled at Resident #1 and denied making insulting or ridiculing statements to him/her. Although CNA #1 said it was CNA #2 that verbally abused Resident #1, CNA #1 also did not intervene to stop CNA #2 and did not report CNA #2's behavior to the nurse. During a telephone interview on 4/04/25 at 9:20 A.M., CNA #2 said that she and CNA #1 cared for Resident #1 following an episode of incontinence on 3/09/25 during the overnight shift. CNA #2 said that CNA #1 called her to Resident #1's room and said to her (CNA #2) look at this, referring to Resident #1 and his/her soiled bed. CNA #2 said she did ask Resident #1 why he/she didn't put on his/her call light so that they could have taken him/her to the bathroom, but denied saying it an abusive manner. CNA #2 said that CNA #1 suggested that they clean Resident #1 by taking him/her to the shower and Resident #1 agreed. CNA #2 said that she stood in the shower room door while CNA #1 and went into the shower assisted Resident #1. CNA #2 said CNA #1 made insulting and ridiculing comments toward Resident #1 during the shower. CNA #2 said that during the shower, CNA #1 said this was unacceptable. CNA #2 said she heard CNA #1 say in a frustrated and angry tome of voice, that Resident #1 should have put his/her call light on, that it was two o'clock in the morning and that she (CNA #1) and Resident #1 were not good. CNA #2 said that at one point when Resident #1 had diarrhea during the shower, CNA #1 said to him/her now you're going again and we are not good. CNA #2 said that Resident #1 explained to CNA #1 that he/she did not realize that he/she was moving his/her bowels in the shower and CNA #1 said, in an incredulous tone of voice, you don't know when you have to go? CNA #2 said that when Resident #1 told CNA #1 he/she was finished moving his/her bowels, CNA #1 responded back and said I thought you said you didn't know when you needed to go. You know, don't give me that, this is unacceptable. CNA #2 said that when the shower was completed, CNA #1 handed Resident #1 a towel and said dry yourself off, I'm not going to do it, I've done enough. CNA #2 said that she was present when CNA #1 yelled at and made insulting and ridiculing comments toward Resident #1. CNA #2 denied that she yelled at Resident #1 and denied making insulting or ridiculing statements to him/her. Although CNA #2 said it was CNA #1 that verbally abused Resident #1, CNA #2 also did not intervene to stop CNA #1 and did not report CNA #1's behavior to the nurse. Both CNA #1 and CNA #2 had initially denied that anyone yelled at Resident #1 or make insulting and ridiculing comments directly to him/her, or within his/her earshot. CNA #1 and #2's statements of denial seemed suspect given the consistent and corroborating statements of Resident #1 and Resident #2, who said that both CNA's were verbally abusive to Resident #1 that night. As a result, of the facility's and State Agency's investigations, CNA #1 and #2 changed their stories about the events that occurred on 3/09/25 and accused each other of having made the alleged abusive statements. During an interview on 3/31/25 at 2:00 P.M., with the Director of Nursing and the Administrator, they said that the Facility investigated Resident #1's report to the Unit Manager regarding the actions of CNA #1 and CNA #2. They said that although CNA #1 and CNA #2 initially denied that any disrespectful or verbally abusive comments were uttered toward Resident #1 during the incident on 3/09/25, that during subsequent interviews, CNA #1 and CNA #2 each, then changed their stories and accused the other of having made such comments. On 3/31/25 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. On 3/12/25, CNAs #1 and #2 were suspended pending the outcome of the Facility Investigation and were subsequently terminated. B. Resident #1 was seen by Social Services on 3/13/25, 3/19/25 and 3/26/25 for support related to the alleged incident and was seen by psychiatric services on 3/17/25. C. On 3/19/25, the Administrator attended Residents Council to provide education to residents on the Facility Abuse Policy and to ask resident about other potential concerns related to verbal abuse/resident rights. D. On 3/19/25, the Director of Clinical Compliance reviewed the 2025 Grievances for any concerns related to verbal abuse/resident rights. E. Between 3/19/25 and 3/21/25, the Director of Clinical Compliance and the Staff Development Coordinator trained all Facility staff using a new scenario-based training curriculum targeted toward identifying and responding to resident abuse/resident rights. F. Starting 3/15/25 and on-going, the Social Worker interviewed four Facility residents daily, five days each week, to ask about potential incidents of verbal abuse/resident rights violations. G. The Administrator and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure they were free from verbal and mental abuse by a staff member when, during the night shift (11:00 P.M. to 7:00 A.M.) on 01/29/25 into 01/30/25, Certified Nurse Aide (CNA) #1 was witnessed by two staff members as she yelled at, swore at, and berated Residents #1, #2, and #3, who became embarrassed, upset, and cried. Resident #1 also reported to staff that he/she was afraid of CNA #1. Findings include: Review of the Facility's Policy titled, Abuse Investigation and Reporting, dated as revised February 2024, indicated the following: -verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability, and -staff will maintain a manner of courtesy and respect toward residents and their families. 1. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 01/30/25, indicated that Resident #1 said CNA #1 was verbally abusive to him/her. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Resident #1 told Nurse #1 that CNA #1 yelled at him/her while she (CNA #1) provided care. The Report indicated that during an interview, Resident #1 told the Director of Social Services that CNA #1 had made him/her cry. Resident #1 was admitted to the Facility in April 2023, diagnoses included polyosteoarthritis (arthritis in five or more joints) and stroke. Review of Resident #1's Quarterly MDS Assessment, dated 12/18/24 indicated that Resident #1 was alert, oriented, able to make self-understood and understood others, and his/her Brief Interview for Mental Status (BIMS) score was 14 out of 15 (score of 0-7 indicates severe cognitive impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact). The MDS indicated Resident #1 was dependent on staff to meet his/her care needs. During an interview on 02/27/25 at 1:00 P.M. (which included a review of his/her witness statement, documented by the Director of Social Services dated 01/30/25), Resident #1 said that on 01/30/25 sometime between 3:30 A.M. and 4:00 A.M., he/she was constipated and asked CNA #1 for help. Resident #1 said CNA #1 responded by yelling at him/her saying, you're faking it! and I'm not sticking my finger up your ass! Resident #1 said that CNA #1 embarrassed and upset him/her and made him/her cry. During an interview on 02/27/25 at 11:54 A.M., the Director of Social Services said that when she interviewed Resident #1, he/she (Resident #1) told her that CNA #1 had been very rude to him/her, yelled at him/her, and made him/her very upset. During a telephone interview on 02/27/25 at 2:02 P.M., (which included a review of her written witness statement), CNA #2 said Resident #1 was constipated, that she heard CNA #1 say to Resident #1, we are not sticking our fucking fingers up your ass. CNA #2 said she also heard CNA #1 say to Resident #1, I am not your fucking friend, I am here to clean your ass. During a telephone interview on 02/28/25 at 1:29 P.M., (which included a review of her written witness statement, undated), Nurse #1 said that during the night shift (on 01/29/25 into 01/30/25), she heard CNA #1 yelling and swearing at Resident #1, which made him/her cry. Nurse #1 said she heard CNA #1 tell Resident #1 she would leave him/her on the bed pan for two hours if he/she acted up again. Nurse #1 said she also heard CNA #1 say to Resident #1, we are not sticking our fingers in your fucking asshole to make you shit. Nurse #1 said Resident #1 asked for her (Nurse #1) later in the morning (sometime around 6:30 A.M.) and said he/she (Resident #1) was afraid of CNA #1. 2. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Nurse #1 said she heard CNA #1 say, what do you want? to Resident #2 which made him/her cry. The Report indicated that Nurse #1 said CNA #1 then said, why is everyone crying tonight? Resident #2 was admitted to the Facility in July 2021, diagnoses included stroke, chronic obstructive pulmonary disease, dementia, and major depressive disorder. Review of Resident #2's Quarterly MDS Assessment, dated 11/27/24, indicated he/she had moderate cognitive impairment, with a BIMS score of 9 out of 15, and that he/she was dependent on staff to meet his/her care needs. During an interview on 02/27/25 at 1:20 P.M., Resident #2 said he/she did not remember any staff member yelling at him/her on 01/30/25. During an interview on 02/27/25 at 11:54 A.M., the Director of Social Services said that when she interviewed Resident #2 on 1/30/25, he/she said he/she had no recollection of CNA #1 yelling at him/her. During a telephone interview on 02/27/25 at 2:02 P.M., (which included a review of her written witness statement), CNA #2 said that sometime after 12:30 A.M., Resident #2 began to frequently asking staff to either open or close his/her window during the night because he/she had difficulty breathing. CNA #2 said she heard CNA #1 yell while she (CNA #1) was standing outside Resident #2's room, he/she (Resident #2) has been doing this (asking for window to be opened or closed) all fucking night. CNA #2 said CNA #1's remark made Resident #2 cry. During a telephone interview on 02/28/25 at 1:29 P.M., (which included a review of her written witness statement, undated), Nurse #1 said that Resident #2 receives hospice services, has respiratory issues, and frequently asks for his/her window to be opened or closed throughout the night to help with his/her breathing. Nurse #1 said that sometime between 2:30 A.M. to 3:30 A.M., Resident #2 activated his/her call light and asked for his/her window to be either opened and/or closed (could not recall which). Nurse #1 said she could not remember exactly what CNA #1 said, but that she heard CNA #1 yell at Resident #2 until he/she (Resident #2) began to cry. Nurse #1 said CNA #1 then yelled, and now this one is fucking crying too! and why is everyone crying? 3. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Nurse #1 said that Resident #3 went to the Nurses' Station and asked for cranberry juice, and CNA #1 told him/her he/she could not have any. Resident #3 was admitted to the Facility in August 2019, diagnoses included dementia, bulimia nervosa (eating disorder), legal blindness, and major depressive disorder. Review of Resident #3's Quarterly Minimum Date Set (MDS) Assessment, dated 01/31/25, indicated he/she was cognitively intact, he/she had a BIMS score of 13/15, and was dependent on staff to meet his/her care needs. During an interview on 02/27/25 at 11:54 A.M., the Director of Social Services said that on 1/30/25, when she interviewed Resident #3, he/she said he/she had no recollection of CNA #1 yelling at him/her. During a telephone interview on 02/27/25 at 2:02 P.M., (which included a review of her written witness statement), CNA #2 said on 1/30/25 sometime around 12:30 A.M., Resident #3 came out of his/her room and asked for juice. CNA #2 said CNA #1 responded and said to Resident #1 no, because you will shit yourself. CNA #2 said Resident #3 kept apologizing to CNA #1 and then sat on his/her rollator (rolling walker with built-in seat) and put his/her head down. CNA #2 said Resident #3 looked sad. During an interview on 02/27/25 at 1:20 P.M., Resident #3 said he/she did not remember anyone yelling at him/her. During a telephone interview on 02/28/25 at 1:29 P.M., (which included a review of her written witness statement, undated), Nurse #1 said that she, CNA #1, and CNA #2 were sitting at the Nurses' Station when Resident #3 walked up to them and asked CNA #1 for juice. Nurse #1 said that CNA #1 said to Resident #3, absolutely not, you will shit your pants, and then said to Resident #3 you are disgusting. Although Residents #2 and #3 said they did not remember being yelled at and berated by CNA #1 on 01/30/25 during the overnight shift, Nurse #1's and CNA #2's recounting of the events that night supports the residents' were verbally and mentally abused by CNA #1 that night. A reasonable person would have experienced mental anguish after being treated by a caregiver, who they were dependent on for care, in this manner. During an interview on 02/27/25 at 2:33 P.M., the Director of Nurses (DON) said that Nurse #1 told her that CNA #1 had been yelling at residents during the night shift (11:00 P.M. - 7:00 A.M.) that began on 01/29/25. The DON said she interviewed CNA #1 and she (CNA #1) denied the allegations of verbal abuse, refused to write a witness statement, and then resigned from the Facility. The DON said the Facility did not substantiate the allegations of verbal abuse because CNA #1 denied the allegations.

Based on records reviewed and interviews, for three of three sampled residents (Residents #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy to prevent the potential for further abuse, when on 01/30/25 during the night shift, although Nurse #1 witnessed and was therefore aware [sometime around 12:30 A.M.], that Certified Nurse Aide (CNA) #1 had verbally abused Residents #3, she did not immediately report the abuse to facility management, as required. CNA #1 was not put on administrative leave after the first incident that night and worked the entire night shift on the same unit providing care and having access to other residents. As a result, CNA #1 verbally and mentally abused Resident #1 and #2, later that same night. Nurse #1 waited and reported all three incidents of abuse to the Director or Nurses (DON) at the end of the night shift, sometime around 7:00 A.M., more than six hours after the first incident occurred. Findings include: Review of the Facility's Policy, titled, Abuse Investigation and Reporting, dated as revised February 2024, indicated it included, but was not limited to the following: -upon receiving report of an allegation of abuse, neglect or misappropriation of resident property, or injury of unknown etiology, the staff member receiving an allegation, witnessing a potentially inappropriate treatment, or observing an injury of unknown etiology will report the event immediately to the nursing supervisor/management, and; - if the suspected perpetrator is an employee, the employee will be placed on administrative leave pending the completion of an investigation. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Nurse #1 said that Resident #3 came out to the Nurses' Station and asked for cranberry juice, and CNA #1 told him/her he/she could not have any. Resident #3 was admitted to the Facility in August 2019, diagnoses included dementia, bulimia nervosa (eating disorder), legal blindness, and major depressive disorder. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 01/31/25, indicated he/she was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (score of 0-7 indicates severe cognitive impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact). The MDS indicated Resident #3 was dependent on staff to meet his/her care needs. During a telephone interview on 02/27/25 at 2:02 P.M., (which included a review of her written witness statement), CNA #2 said she could not remember the exact time, but that sometime around 12:30 A.M. on 01/30/25, Resident #3 came out of his/her room to the nursing station and asked for juice. CNA #2 said she, CNA #1 and Nurse #1, were all the nursing station at that time. CNA #2 said CNA #1 yelled at Resident #3 and said to him/her no juice, because you will shit yourself! During a telephone interview on 02/28/25 at 1:29 P.M., (which included a review of her written witness statement, undated), Nurse #1 said that during the night shift (on 01/29/25 into 1/30/25) she witnessed CNA #1 yell and swear [used profanity] at three residents (#1, #2, and #3). Nurse #1 said the incidents started sometime around 12:30 A.M. when CNA #1 refused to give Resident #3 juice, then yelled at him/her and said, you cannot have juice, you will shit your pants and that CNA #1 then said to Resident #3, you are disgusting. Nurse #1 said there was no Nursing Supervisor working in the facility during the night shift and that she was unsure of who to call. Nurse #1 said after she heard CNA #1 yell at Resident #1, she instructed CNA #1 to stay away from him/her. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Nurse #1 said she heard CNA #1 say, what do you want? to Resident #2, which made him/her cry. The Report indicated that Nurse #1 said CNA #1 then said, why is everyone crying tonight? Resident #2 was admitted to the Facility in July 2021, diagnoses included stroke, chronic obstructive pulmonary disease, dementia, and major depressive disorder. Review of Resident #2's Quarterly MDS Assessment, dated 11/27/24 indicated he/she had moderate cognitive impairment, with a BIMS score of 9 out of 15, and that he/she was dependent on staff to meet his/her care needs. CNA #2 said that sometime after 12:30 A.M., (exact time unknown) Resident #2 began to frequently ask staff to either open or close his/her window during the night. CNA #2 said she heard CNA #1 yell while she (CNA #1) was standing outside Resident #2's room, he/she (Resident #2) has been doing this (asking for window to be opened or closed) all fucking night. CNA #2 said CNA #1's remark made Resident #2 cry. Nurse #1 said that Resident #2 was receiving hospice services, has respiratory issues, and frequently asks staff for his/her window to be opened or closed throughout the night to help with his/her breathing. Nurse #1 said that sometime between 2:30 A.M. to 3:30 A.M., (exact time unknown) Resident #2 activated his/her call light again and asked for his/her window to be either opened and/or closed (could not recall which). Nurse #1 said she could not remember exactly what CNA #1 said, but that she heard CNA #1 yell at Resident #2 until he/she (Resident #2) began to cry. Nurse #1 said CNA #1 then yelled, and now this one is fucking crying too! and why is everyone crying? Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 01/30/25, indicated that Resident #1 said CNA #1 was verbally abusive to him/her. Review of the Facility's Investigation Report, undated, indicated that on 01/30/25, Resident #1 told Nurse #1 that CNA #1 yelled at him/her while she (CNA #1) provided care. The Report indicated that during an interview, Resident #1 told the Director of Social Services that CNA #1 had made him/her cry. Resident #1 was admitted to the Facility in April 2023, diagnoses included polyosteoarthritis (arthritis in five or more joints) and stroke. Review of Resident #1's Quarterly MDS Assessment, dated 12/18/24, indicated that Resident #1 was alert, oriented, able to make self-understood and understood others, his/her Brief Interview for Mental Status (BIMS) score was 14 out of 15, and was dependent on staff to meet his/her care needs. During an interview on 02/27/25 at 1:00 P.M. (which included a review of his/her witness statement, documented by the Director of Social Services dated 01/30/25), Resident #1 said that on 01/30/25 sometime between 3:30 A.M. and 4:00 A.M., he/she asked CNA #1 for help. Resident #1 said CNA #1 responded by yelling at and embarrassing him/her, which upset him/her and made him/her cry. CNA #2 said later that night (exact time unknown) she heard CNA #1 say to Resident #1, we are not sticking our fucking finger up your ass. CNA #2 said she also heard CNA #1 say to Resident #1, I am not your fucking friend, I am here to clean your ass. CNA #2 said she did not report the incidents because Nurse #1 was already aware of them. Nurse #1 said she also heard CNA #1 yelling and swearing at Resident #1 and then saw Resident #1 crying. Nurse #1 said she heard CNA #1 tell Resident #1 that she would leave him/her on the bed pan for two hours if he/she acted up again, and then heard CNA #1 say to him/her, we are not sticking our fingers in your fucking asshole to make you shit. Nurse #1 said she did not immediately report the verbal abuse incident with Resident #3 [that occurred on 1/30/25 around 12:30 A.M.] to administrative staff but waited until the morning at the end of her shift [7:00 A.M.] and reported all three incidents to the Director of Nurses (DON) at that time. Nurse #1 said she had not sent CNA #1 home after the incident with Resident #3, and that CNA #1 worked the entire night shift (11:00 P.M. to 7:00 A.M.) providing care to residents. During an interview on 02/27/25 at 2:33 P.M., the Director of Nurses (DON) said that Nurse #1 and CNA #2 should have immediately notified her as soon as they witnessed CNA #1 yell and swear at any of the residents during their shift that night, but they had not. The DON said CNA #1 should have been removed from the Facility that night. The DON said she was not notified of the incidents until she arrived at the Facility the following morning (01/30/25, exact time unknown), when Nurse #1 reported them to her. The DON said staff did not follow facility policy.

Based on observations, interviews, and record review, the facility failed to protect Resident #141's right to be free from verbal abuse by Resident #105. The total sample was 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to develop and implement effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization. Findings include: Review of the facility's policy titled Abuse Investigating and Reporting, revised in February 2024, indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged violations are reported to the Administrator and to other officials in accordance with state law -alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process -the results of investigations must be reported in accordance with state/federal law within five business days of the incident -if the alleged violation is verified appropriate corrective actions must be taken -report to DPH (Department of Public Health) and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of the facility -if the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but not later than two hours) after forming the suspicion; otherwise the report must not be made later than 24 hours after forming the suspicion. Crime is defined by local law jurisdiction. -any suspected allegation of abuse shall be reported to the Administrator or his/her designee -if the suspected perpetrator is another resident, the residents shall be separated so they do not have access to each other until the circumstances of the alleged incident can be determined -the staff member witnessing a potentially inappropriate treatment will report the event immediately to the nursing supervisor/management -the nursing supervisor/designee will take appropriate steps to protect the resident from further mistreatment through: separating the accused/suspected resident from the alleged victim and other residents; provide emotional support to alleged victim if needed -interview appropriate individuals; which may include the alleged victim, employees working during the shift when the event was discovered/reported, as well as other residents who may have witnessed something -the Social Worker may interview other potential victims Resident #141 was admitted to the facility in January 2025 for short term rehabilitation and was receiving physical and occupational therapy services. Review of the Minimum Data Set (MDS) assessment, dated 1/13/25, indicated Resident #141 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, and was a smoker. Resident #105 was admitted to the facility in December 2024 for short term rehabilitation and was receiving physical therapy services. Review of the MDS assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact, and was a smoker. During an interview with observation on 1/30/25 at 2:10 P.M., the surveyor observed Resident #141 crying. The Resident said he/she was listening to his/her music earlier in the day when Resident #105, while on their way to Rehab, said, Why are you listening to that? I don't want to hear Nxxxxx music. Resident #141 said he/she did not know why Resident #105 did not like him/her. Resident #141 said there had been other negative encounters with Resident #105 saying he/she smelled and using racial slurs. Resident #141 said that Resident #105 could say whatever they wanted, but he/she couldn't. The Resident felt he/she needed to censor him/herself and couldn't allow him/herself to burst out in these situations in response to Resident #105. Resident #141 went on to say that he/she tries to stay in his/her room, as he/she had a TV and iPad he/she could use to pass time. Resident #141 said after today's incident, he/she will stay in his/her room and will not be going to communal places within the facility (such as the drop-in day room) as to avoid situations like today. Resident #141 said he/she was going to just sit in his/her bed in the current spot and that's where the surveyor will find him/her next week when the surveyor returned. Review of the medical record for Resident #105 indicated that on 1/7/25 Resident #105 was screaming racial slurs at new roommate (Resident #141) and the Resident became aggressive with redirection. Resident #105 was sent to the hospital for a change in mental status. Further review indicated Resident #105 had a room change on 1/7/25 so that he/she was not rooming with Resident #141. Resident #105 was moved two rooms down, diagonally across the hall from Resident #141. Review of the emergency room After Visit Summary from 1/7/25 indicated Resident #105 presented with agitation and included an educational attachment for Intermittent Explosive Disorder which included treatment goals to stop outbursts through the use of cognitive behavioral therapy, group therapy, relaxation methods and medications. Review of the progress notes and care plans for Resident #105 failed to address behaviors and failed to identify interventions. Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall. During an interview with the Administrator and the Director of Nurses (DON) on 1/30/25 at 2:42 P.M., the Administrator said he was unaware of the verbal altercation between Resident #141 and Resident #105 today. The DON said she was aware that Resident #105 had used racial slurs towards Resident #141 today on the way to attend physical therapy together and the staff were working on a plan to keep the residents separated. She said Resident #105 previously had a verbal altercation with Resident #141 when Resident #141 was admitted to the facility and a room change was initiated. She said she was unaware Resident #105 had used racial slurs during that altercation. During an interview on 1/30/25 at 2:40 P.M., Nurse #3 said she had been working on 1/7/25 when Resident #105 called Resident #141 a nxxxxx and said Resident #141 was making the room smell like a zoo. She said Resident #141 was so upset that he/she started crying because of the racial slurs that were hurled at him/her by Resident #105. Nurse #3 said she notified Nurse #1 who was the nursing supervisor. During an interview on 1/30/25 at 2:43 P.M., Certified Nursing Assistant (CNA) #1 said she was the assigned CNA for Resident #105 and Resident #141. She said about three weeks prior, Resident #105 had made racial comments to Resident #141, and they switched the room of Resident #105 to across the hall. She said she was not aware if there had been any additional plan to keep the residents separated. During an interview on 1/30/25 at 2:50 P.M., CNA #3 said on 1/7/25 Resident #105 had said he/she did not like black people and did not want Resident #141 in his/her room. She said Resident #105 was yelling that Resident #141 was nasty and smelled nasty and their room was going to smell nasty now and she felt this was directly related to race. The CNA said she immediately notified the nurse who notified the supervisor and the DON. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called down to the unit to assist as Resident #105 was yelling about Resident #141 saying that he/she smelled and was calling the Resident the N word. She said the plan at that time was to split up the two residents right way and moved Resident #105 across the hall. She said on 1/7/25, Resident #141 was very sensitive about this and was crying. She said another verbal altercation was bound to happen between the two residents. During an interview on 1/31/25 at 3:23 P.M., CNA #6 said on 1/7/25 she found Resident #141 in his/her room crying. CNA #6 said Resident #105 had called Resident #141 a nxxxxx. She said Resident #105 kept yelling and Resident #141 did not want to stay. The CNA said the Nurse Scheduler had come to assist separating the residents and the DON was contacted as well. In addition, CNA #6 said Resident #105 often uses profanities, and if smoking break is late, Resident #105 will call the staff bxxxxes and nxxxxxxs. During an interview on 1/30/25 at 2:40 P.M., CNA #5 said she was not aware there had been any altercations before today and normally works on the unit with both residents. During an interview on 1/30/25 at 2:40 P.M., CNA #4 said she was not aware there had been any altercations before today and normally works on the unit with both residents. During an interview on 1/31/25 at 9:45 A.M., Social Worker #1 said she was in the facility on 1/7/25 and went to the unit when Resident #105 was yelling. She said she heard Resident #105 yelling, This is gross, he/she smells like shit. She said Resident #141 was crying and said, This always happens to me. She said she did not directly hear any racist comments but had been told by staff that Resident #105 was saying racial slurs to Resident #141. She said the interdisciplinary team discussed this at morning meeting the next day and she thought the plan was to keep them separated. She said she would not have been involved in any staff education for this and it would have been completed by the Staff Development Coordinator (SDC). The Social Worker said at this facility the Social Service staff were not involved in documenting behaviors or implementing behavioral care plans or behavioral interventions. During an interview on 2/4/25 at 3:47 P.M., the SDC said she was at the facility on 1/7/25 when the altercation occurred. She said she was aware Resident #105 had used racial slurs towards Resident #141. She said the plan was to move the room of Resident #105 and there were no additional interventions. She said she did not provide any staff education on keeping the two residents separated. During an interview on 1/31/25 at 10:00 A.M., the Nurse Scheduler said he went to the unit when Resident #105 was yelling at Resident #141. He said he had not heard Resident #105 saying any racial slurs, but that Resident #141 had told him about the racial slurs. He said he offered Resident #141 support as the Resident was visibly very upset. During an interview on 2/4/25 at 8:48 A.M., the Activity Director said Resident #105 and Resident #141 attend the drop-in center (where residents can come and go at their leisure) and both residents attend the smoking breaks regularly. She said she was unaware there were any altercations between the two residents prior to 1/30/25. During an interview on 2/4/25 at 1:45 P.M., the DON confirmed there was no investigation to review for the verbal abuse that occurred between Resident #105 and Resident #141 on 1/7/25. During an interview on 1/30/25 at 5:15 P.M., the Administrator said the police had met with both Resident #105 and Resident #141 today. The Administrator said the plan was for Resident #105 to be checked on by staff every 15 minutes. He said both residents had refused to change rooms at this time. The Administrator said he had just discovered that both residents attend the smoking breaks and he would need to initiate a plan for this. During an interview on 1/31/25 at 9:25 A.M., Resident #141 said he/she did not understand why Resident #105 did not like him/her and when he/she asked Resident #105 a couple of days prior Resident #105 had responded with go f*** yourself. Resident #141 went on to talk about the racial slurs Resident #105 had used the previous day and Resident #141 said he/she had gotten so upset that he/she had started to lose their temper and raised their voice and was trying hard to control themselves and not retaliate. During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25 he went to the room of Resident #141 and asked the Resident to get ready to come down to the rehab gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior. He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive. The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry, and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting. During an interview on 1/31/25 at 9:30 A.M., the Director of Rehabilitation (Rehab) said she was not sure of the specifics from the previous day, which involved a Physical Therapy Assistant (PTA) and she would have to get back to the surveyor on what the plan was for Resident #105 and Resident #141 who were both receiving rehab services. She said that the residents should not be in rehab at the same time but that only the PTA needed to know this because he was the only staff who worked with both residents. During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day (1/30/25) but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted . The COTA said he had not heard anything since then and had never been told to keep the residents separated. During an interview on 1/31/25 at 9:45 A.M., Social Work Consultant #2 said she met with Resident #141 following the verbal abuse on 1/30/25 and Resident #141 told her the racial comments from Resident #105 had been occurring daily. During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention. The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated and reported. The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall. The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day. The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs. The Administrator said this could weigh a lot on someone psychosocially. Refer to F607, F609, F610, F656, F740, and F745

Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedures to prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization. Findings include: Review of the facility's policy titled Abuse Investigating and Reporting, revised in February 2024, indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged violations are reported to the Administrator and to other officials in accordance with state law -alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process -the results of investigations must be reported in accordance with state/federal law within five business days of the incident -if the alleged violation is verified appropriate corrective actions must be taken -report to DPH (Department of Public Health) and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of the facility -if the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but not later than two hours) after forming the suspicion; otherwise the report must not be made later than 24 hours after forming the suspicion. Crime is defined by local law jurisdiction. -any suspected allegation of abuse shall be reported to the Administrator or his/her designee -if the suspected perpetrator is another resident, the residents shall be separated so they do not have access to each other until the circumstances of the alleged incident can be determined -the staff member witnessing a potentially inappropriate treatment will report the event immediately to the nursing supervisor/management -the nursing supervisor/designee will take appropriate steps to protect the resident from further mistreatment through: separating the accused/suspected resident from the alleged victim and other residents; provide emotional support to alleged victim if needed -interview appropriate individuals; which may include the alleged victim, employees working during the shift when the event was discovered/reported, as well as other residents who may have witnessed something -the Social Worker may interview other potential victims Resident #141 was admitted to the facility in January 2025 for short term rehabilitation and was receiving physical and occupational therapy services. Review of the Minimum Data Set (MDS) assessment, dated 1/13/25, indicated Resident #141 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and was a smoker. Resident #105 was admitted to the facility in December 2024 for short term rehabilitation and was receiving physical therapy services. Review of the MDS assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact and was a smoker. During an observation with interview on 1/30/25 at 2:10 P.M., the surveyor observed Resident #141 from their doorway. The Resident did not wave or smile to the surveyor and was visibly upset. The surveyor entered the Resident's room and observed Resident #141 crying. During an interview at this time, the Resident said he/she was listening to his/her music earlier in the day when Resident #105, on the way to Rehab, said, Why are you listening to that? I don't want to hear Nxxxxx music. Resident #141 said he/she did not know why Resident #105 did not like him/her. Resident #141 said there had been other negative encounters with Resident #105 saying he/she smelled and using racial slurs. Resident #141 said he/she tries to stay in his/her room, as he/she had a TV and iPad he/she could use to pass time. Resident #141 said after today's incident, he/she will stay in his/her room and will not be going to communal places within the facility (such as the drop-in day room) as to avoid situations like today. Resident #141 said he/she was going to just sit in his/her bed in the current spot and that's where the surveyor will find him/her next week when the surveyor returned. Review of the medical record for Resident #105 indicated on 1/7/25 Resident #105 was screaming racial slurs at new roommate (Resident #141) and the Resident became aggressive with redirection. Resident #105 was sent to the hospital for change in mental status. Further review indicated Resident #105 had a room change on 1/7/25 so that he/she was not rooming with Resident #141. Resident #105 was moved two rooms down, diagonally across the hall from Resident #141. Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall. During an interview on 1/30/25 at 2:42 P.M., the Director of Nurses (DON) said Resident #105 had previously had a verbal altercation with Resident #141 when Resident #141 was admitted to the facility and a room change was initiated and she was unaware Resident #105 had used racial slurs during that altercation. During an interview on 1/30/25 at 2:40 P.M., Nurse #3 said she had been working on 1/7/25 when Resident #105 called Resident #141 a nxxxxx and said Resident #141 was making the room smell like a zoo. She said Resident #141 was so upset that he/she started crying because of the racial slurs that were hurled at him/her by Resident #105. Nurse #3 said she notified Nurse #1 who was the nursing supervisor. During an interview on 1/30/25 at 2:43 P.M., Certified Nursing Assistant (CNA) #1 said she was the assigned CNA for Resident #105 and Resident #141. She said about three weeks prior Resident #105 had made racial comments to Resident #141, and they switched the room of Resident #105 to across the hall. She said she was not aware if there had been any additional plan to keep the residents separated. During an interview on 1/30/25 at 2:50 P.M., CNA #3 said on 1/7/25 Resident #105 had said he/she did not like black people and did not want Resident #141 in his/her room. She said Resident #105 was yelling that Resident #141 was nasty and smelled nasty and their room was going to smell nasty now and she felt this was directly related to race. The CNA said she immediately notified the nurse who notified the supervisor and the DON. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called down to the unit to assist as Resident #105 was yelling about Resident #141 saying that he/she smelled and was calling the Resident the N word. She said the plan at that time was to split up the two residents right way and moved Resident #105 across the hall. She said on 1/7/25 Resident #141 was very sensitive about this and was crying. She said another verbal altercation was bound to happen between the two residents. During an interview on 1/31/25 at 3:23 P.M., CNA #6 said on 1/7/25 she found Resident #141 in his/her room crying. CNA #6 said Resident #105 had called Resident #141 a nxxxxx. She said Resident #105 kept yelling and Resident #141 did not want to stay. The CNA said the Nurse Scheduler had come to assist separating the residents and the DON was contacted as well. In addition, CNA #6 said Resident #105 often uses profanities, and if smoking break is late, Resident #105 will call the staff bxxxxxs and nxxxxxs. During an interview on 1/31/25 at 9:45 A.M., Social Worker #1 said she was in the facility on 1/7/25 and went to the unit when Resident #105 was yelling. She said she heard Resident #105 yelling, this is gross, he/she smells like shit. She said Resident #141 was crying and said, this always happens to me. She said she did not directly hear any racist comments but had been told by staff that Resident #105 was saying racial slurs to Resident #141. She said the interdisciplinary team discussed this at morning meeting the next day and she thought the plan was to keep them separated. She said she would not have been involved in any staff education for this and it would have been completed by the Staff Development Coordinator (SDC). During an interview on 2/4/25 at 3:47 P.M., the SDC said she was at the facility on 1/7/25 when the altercation occurred. She said she was aware Resident #105 had used racial slurs towards Resident #141. She said the plan was to move the room of Resident #105 and there were no additional interventions. She said she did not provide any staff education on keeping the two residents separated. During an interview on 2/4/25 at 8:48 A.M., the Activity Director said Resident #105 and Resident #141 attend the drop-in center (where residents can come and go at their leisure) and both residents attend the smoking breaks regularly. She said she was unaware there were any altercations between the two residents prior to 1/30/25. During an interview on 2/4/25 at 1:45 P.M., the DON confirmed there was no investigation to review for the verbal abuse that occurred between Resident #105 and Resident #141 on 1/7/25. During an interview on 1/31/25 at 9:25 A.M., Resident #141 said he/she did not understand why Resident #105 did not like him/her and when he/she asked Resident #105 a couple of days prior Resident #105 had responded with go f*** yourself. Resident #141 went on to talk about the racial slurs Resident #105 had used the previous day and Resident #141 said he/she had gotten so upset that he/she had started to lose their temper and raised their voice and was trying hard to control themselves and not retaliate. During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25 he went to the room of Resident #141 and asked the Resident to get ready to come down to the rehab gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior. He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive. The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting. During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day, 1/30/25 but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted . The COTA said he had not heard anything since then and had never been told to keep the residents separated. During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention. The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated and reported. The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall. The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day. The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs. The Administrator said this could weigh a lot on someone psychosocially. Refer to F609 and F610

Based on observation, interview, and record review, the facility failed to implement their policy and procedures to investigate and prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to conduct a thorough investigation and initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease socialization. Findings include: Review of the facility policy titled Abuse Investigating and Reporting, revised in February 2024 indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged violations are reported to the Administrator and to other officials in accordance with state law. -alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process -the results of investigations must be reported in accordance with state/federal law within five business days of the incident - if the alleged violation is verified appropriate corrective actions must be taken -any suspected allegation of abuse shall be reported to the Administrator or his/her designee -if the suspected perpetrator is another resident, the residents shall be separated so they do not have access to each other until the circumstances of the alleged incident can be determined -the staff member witnessing a potentially inappropriate treatment will report the event immediately to the nursing supervisor/management -the nursing supervisor/designee will take appropriate steps to protect the resident from further mistreatment through: separating the accused/suspected resident from the alleged victim and other residents; provide emotional support to alleged victim if needed -interview appropriate individuals; which may include the alleged victim, employees working during the shift when the event was discovered/reported, as well as other residents who may have witnessed something -the Social Worker may interview other potential victims Resident #141 was admitted to the facility in January 2025 for short term rehabilitation and was receiving physical and occupational therapy services. Review of the Minimum Data Set (MDS) assessment, dated 1/13/25, indicated Resident #141 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and was a smoker. Resident #105 was admitted to the facility in December 2024 for short term rehabilitation and was receiving physical therapy services. Review of the MDS assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact and was a smoker. On 1/30/25 at 2:10 P.M., the surveyor observed Resident #141 from their doorway. The Resident did not wave or smile to the surveyor and was visibly upset. The surveyor entered the Resident's room and observed Resident #141 crying. During an interview at this time, the Resident said he/she was listening to his/her music earlier in the day on the way to Rehab when Resident #105 said Why are you listening to that? I don't want to hear Nxxxxx music. Resident #141 said he/she did not know why Resident #105 did not like him/her. Resident #141 said there had been other negative encounters with Resident #105 saying he/she smelled and using racial slurs. Resident #141 said he/she tries to stay in his/her room, as he/she had a TV and iPad he/she could use to pass time. Resident #141 said after today's incident, he/she will stay in his/her room and will not be going to communal places within the facility (such as the drop-in day room) as to avoid situations like today. Resident #141 said he/she was going to just sit in his/her bed in the current spot and that's where the surveyor will find him/her next week when the surveyor returned. Review of the medical record for Resident #105 indicated on 1/7/25 Resident #105 was screaming racial slurs at roommate (Resident #141) and the Resident became aggressive with redirection. Resident #105 was sent to the hospital for a change in mental status. Further review indicated Resident #105 had a room change on 1/7/25 so that he/she was not rooming with Resident #141. Resident #105 was moved two rooms down, diagonally across the hall from Resident #141. Review of the emergency room After Visit Summary from 1/7/25 indicated Resident #105 presented with agitation and included an educational attachment for Intermittent Explosive Disorder which included treatment goals to stop outbursts through the use of cognitive behavioral therapy, group therapy, relaxation methods and medications. Review of the progress notes and care plans for Resident #105 failed to address behaviors and failed to identify interventions. Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall. During an interview on 1/30/25 at 2:42 P.M., the Director of Nurses (DON) said Resident #105 had previously had a verbal altercation with Resident #141 when Resident #141 was admitted to the facility and a room change was initiated. She was unaware Resident #105 had used racial slurs during that altercation. During an interview on 1/30/25 at 2:40 P.M., Nurse #3 said she had been working on 1/7/25 when Resident #105 called Resident #141 a nxxxxx and said Resident #141 was making the room smell like a zoo. She said Resident #141 was so upset that he/she started crying because of the racial slurs that were hurled at him/her by Resident #105. Nurse #3 said she notified Nurse #1 who was the nursing supervisor. During an interview on 1/30/25 at 2:43 P.M., Certified Nursing Assistant (CNA) #1 said she was the assigned CNA for Resident #105 and Resident #141. She said about three weeks prior Resident #105 had made racial comments to Resident #141, and they switched the room of Resident #105 to across the hall. She said she was not aware if there had been any additional plan to keep the residents separated. During an interview on 1/30/25 at 2:50 P.M., CNA #3 said on 1/7/25 Resident #105 had said he/she did not like black people and did not want Resident #141 in his/her room. She said Resident #105 was yelling that Resident #141 was nasty and smelled nasty and their room was going to smell nasty now and she felt this was directly related to race. The CNA said she immediately notified the nurse who notified the supervisor and the DON. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called down to the unit to assist as Resident #105 was yelling about Resident #141 saying that he/she smelled and was calling the Resident the N word. She said the plan at that time was to split up the two residents right way and moved Resident #105 across the hall. She said on 1/7/25 Resident #141 was very sensitive about this and was crying. She said another verbal altercation was bound to happen between the two residents. During an interview on 1/31/25 at 3:23 P.M., CNA #6 said on 1/7/25 she found Resident #141 in his/her room crying. CNA #6 said Resident #105 had called Resident #141 a nxxxxx. She said Resident #105 kept yelling and Resident #141 did not want to stay. The CNA said the Nurse Scheduler had come to assist separating the residents and the DON was contacted as well. In addition, CNA #6 said Resident #105 often uses profanities and if smoking break is late Resident #105 will call the staff bxxxxxs and nxxxxxs. During an interview on 1/31/25 at 9:45 A.M., Social Worker #1 said she was in the facility on 1/7/25 and went to the unit when Resident #105 was yelling. She said she heard Resident #105 yelling this is gross, he/she smells like shit. She said Resident #141 was crying and said this always happens to me. She said she did not directly hear any racist comments but had been told by staff that Resident #105 was saying racial slurs to Resident #141. She said the interdisciplinary team discussed this at morning meeting the next day and she thought the plan was to keep them separated. She said she would not have been involved in any staff education for this and it would have been completed by the Staff Development Coordinator (SDC). During an interview on 2/4/25 at 3:47 P.M., the SDC said she was at the facility on 1/7/25 when the altercation occurred. She said she was aware Resident #105 had used racial slurs towards Resident #141. She said the plan was to move the room of Resident #105 and there were no additional interventions. She said she did not provide any staff education on keeping the two residents separated. During an interview on 2/4/25 at 8:48 A.M., the Activity Director said Resident #105 and Resident #141 attend the drop-in center (where residents can come and go at their leisure) and both residents attend the smoking breaks regularly. She said she was unaware there were any altercations between the two residents prior to 1/30/25. During an interview on 2/4/25 at 1:45 P.M., the DON confirmed there was no investigation to review for the verbal abuse that occurred between Resident #105 and Resident #141 on 1/7/25. During an interview on 1/31/25 at 9:25 A.M., Resident #141 said he/she did not understand why Resident #105 did not like him/her and when he/she asked Resident #105 a couple of days prior Resident #105 had responded with go f*** yourself. Resident #141 went on to talk about the racial slurs Resident #105 had used the previous day and Resident #141 said he/she had gotten so upset that he/she had started to lose their temper and raised their voice and was trying hard to control themselves and not retaliate. During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25 he went to the room of Resident #141 and asked the Resident to get ready to come down to the rehab gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior. He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive. The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting. During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day, 1/30/25 but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted . The COTA said he had not heard anything since then and had never been told to keep the residents separated. During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention. The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated. The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall. The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day. The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs. The Administrator said this could weigh a lot on someone psychosocially.

Based on observation, interviews, and record review, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#105) with anxiety, demonstrated behaviors, and active substance use, out of a total sample of 33 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder, and interventions for active substance use resulting in emergency room visits. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised in November 2017, indicated but was not limited to the following: -behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. -the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. -safety strategies will be implemented immediately if necessary to protect the resident and others from harm. -the resident will be involved in the development and implementation of the care plan. -interventions will be individualized and part of an overall care environment that supports physical functional and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities. -interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. -the care plan will include, as a minimum: a description of the behavioral symptoms (frequency, intensity, duration, outcomes, location, environment, and precipitating factors or situations), targeted and individualized interventions for behavioral and/or psychosocial symptoms, rational for the interventions and approaches, specific and measurable goals for targeted behaviors, and how staff will monitor for the effectiveness of the interventions. Review of the facility's policy titled Substance Use Disorder Policy, revised February 2024, indicated but was not limited to the following: -if residents with a history of Substance Use Disorder are admitted to the facility the nursing staff will be alerted of the resident's history to ensure appropriate measures are taken if warranted. -social services will refer the resident to mental health services/Licensed Drug Addiction Counselor as warranted with a focus on management of relapse risk and maintenance of sobriety. -the interdisciplinary team will evaluate the resident substance use history, risk of relapse, and develop a person-centered plan of care. -residents will be offered counseling from a Licensed Drug Addiction Counselor. -should residents show signs of relapse, the provider will be made aware and the resident's plan of care will be revised as warranted. Resident #105 was admitted to the facility in December 2024 with a new above the knee amputation of the left leg, anxiety, and cannabis dependence. Review of the Minimum Data Set (MDS) assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the nursing progress notes indicated on 12/31/24 Resident #105 returned to the facility at 7:00 P.M. following a personal leave with family. When the Resident returned, he/she was verbally loud and noisy, making inappropriate statements to staff and slurring his/her speech. The nursing progress note indicated the Nurse Practitioner (NP) was contacted with a new order to hold medication and send to the emergency room . The note indicated when Resident #105 was informed of the new orders the Resident became very agitated, threatening to punch someone if he/she did not get their medication. The Resident then went to their room and started throwing around furniture, came back into the hallway swearing, and exposing him/herself to the nurse, while yelling with slurred speech. 911 was called and Resident #105 was sent to the hospital. Review of the Hospital Discharge Summary, dated 1/1/25, indicated Resident #105 was seen in the emergency room for alcohol intoxication where the Resident was restrained related to violence. In the emergency room , the Resident was administered the following injections: Haldol 5 milligrams (mg), Ativan 2 mg, and Benadryl 25 mg. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was working on 12/31/24 when Resident #105 returned and was intoxicated. She said the Resident was yelling and swearing and there were family members of other residents around. Review of the NP's Progress Note, dated 1/3/25, indicated Resident #105 was sent to the emergency room for aggressive behavior and alcohol intoxication with the following plan: -behavior: nursing to provide ongoing support to monitor for any signs of recurrent aggression or agitation and collaborate with behavioral health services if necessary -alcohol intoxication: reinforce strategies to prevent further episodes and consider behavioral counseling or substance use treatment referrals if patient agrees Review of the medical record including assessments, care plans, and progress notes failed to indicate any behavioral interventions were implemented following Resident #105 being intoxicated, yelling, swearing, throwing furniture, and exposing him/herself. Review of the Nursing Progress note, dated 1/3/25, indicated Resident #105 became extremely agitated during a change of the bandage to the amputation, threw the bandage at the nurse, and refused a new dressing. Review of the Nursing Progress note, dated 1/7/25, indicated Resident #105 was yelling and screaming racial slurs at a new Resident (#141) and when staff attempted to redirect the Resident he/she became very aggressive and the Resident was sent to the hospital. Further review indicated Resident #105 had a room change on 1/7/25 so that he/she was not rooming with Resident #141. Resident #105 was moved two rooms down, diagonally across the hall from Resident #141. Review of the emergency room After Visit Summary from 1/7/25 indicated Resident #105 presented with agitation and included an educational attachment for Intermittent Explosive Disorder (recurrent aggressive behavior; disordered aggression) which included treatment goals to stop outbursts through the use of cognitive behavioral therapy, group therapy, relaxation methods, and medications. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called when Resident #105 was yelling racial slurs. She said the Resident was screaming, would not take Ativan (an antianxiety medication) and was sent out the hospital. Review of the medical record, including assessments, progress notes, and care plans, failed to address behaviors of yelling, swearing, being aggressive and saying racial slurs and failed to identify interventions. Review of the Physician's Progress Note, dated 1/8/25, failed to indicate the behaviors and emergency room visit were reviewed. During an interview on 1/30/25 at 2:43 P.M., Certified Nursing Assistant (CNA) #1 said she was the primary CNA for Resident #105. She said the Resident gets upset and yells and she gives the Resident space. She said she did not know any other ways to manage the Resident's behavior. During an interview on 1/30/25 at 2:10 P.M., Resident #141, who was crying, said when he/she was on their way to Rehab today Resident #105 started yelling at him/her about their music and said why are you listening to that? I don't want to hear N***** music. Resident #141 said he/she had previous encounters with Resident #105 using racial slurs. During an interview on 1/30/25 at 2:42 P.M., the Director of Nurses (DON) said on 1/7/25 Resident #105 was yelling and did not want a roommate. Resident #105's room was changed to diagonally across the hall. She said she did not think there were any further concerns between the two residents until today. She said Social Services would have done the follow up with Resident #141. She said there had been a few issues with Resident #105 since admission and Resident #105 had a history of drug and alcohol abuse. Review of the Medication Administration Record (MAR) for January 2025 for Resident #105 included an order to monitor behaviors. Further review of the MAR indicated Resident #105 did not have any behaviors in January 2025. Review of the January 2025 Behavior Monitoring, completed by the CNAs, indicated Resident #105 had the following behaviors: 1/4/25: accusing others, expressing frustration/anger at others, cursing at others, screaming at others 1/17/25: expressing frustration/anger at others 1/22/25: expressing frustration/anger at others 1/26/25: expressing frustration/anger at others Review of the care plans for Resident #105 on 1/30/25 failed to address behaviors of yelling, swearing, being aggressive, saying racial slurs, or substance abuse and failed to identify interventions. During an interview on 1/31/25 at 9:40 A.M., Social Worker #1 said the facility Social Workers do not create or participate in care plans related to behavioral concerns. She said the nursing staff were responsible for behavioral care plans. She said Resident #105 has had behaviors of yelling, screaming, using racial slurs and had been sent out to the hospital for being intoxicated. She said she did not know the Resident was also sent to the hospital on 1/7/25 related to behaviors. She said the contracted psychiatric serivces had a therapist at the facility on Tuesdays and a psychiatric NP at the facility on Fridays. She said she verbally referred residents to the psychiatric clinicians and she could not recall if she ever referred Resident #105. She said the facility had recently contracted with a Substance Use Disorder (SUD) Counselor and she was not sure how the residents were referred to the SUD counselor. She said the interdisciplinary team discussed Resident #105 at morning meeting on Monday 1/27/25, possibly related to smoking and the nursing staff was going to refer the Resident to the psychiatric services. Review of the paper record indicated Resident #105 had consented to be seen by the contracted psychiatric services on 12/24/24. Review of the contracted psychiatric services referral book on 1/31/25 failed to indicate Resident #105 had been referred for services. Review of the medical record failed to indicate Resident #105 had been seen by psychiatric services. During an interview on 1/31/25 at 9:40 A.M., Social Work Consultant #2 said the Social Workers do not create or participate in care plans related to behavioral concerns. She said Resident #105 has had behaviors of yelling, swearing and being verbally aggressive. She said the Resident can be combative in discussions and was screaming and swearing at her on 1/30/25 when she inquired if the Resident would change his/her room. She said she was not sure how the residents were referred to the SUD Counselor and would follow up with the surveyor. During an interview on 2/4/25 at 12:11 P.M., Unit Manager #1 said she was a nurse on the unit prior to becoming the Unit Manager last week. She said the process was for the Unit Manager to enter care plans in the electronic medical record. She said the behavioral care plans were usually a collaboration between the Social Workers and the Unit Manager. She said she was not sure if behavioral interventions were implemented for Resident #105 and she had not initiated a care plan for this Resident. She said the NP had seen Resident #105 following one of the emergency room visits and the NP had come up with the plan and the staff would have followed that. She said she was not sure what that plan was. The Unit Manager reviewed the psychiatric services referral book and said Resident #105 was referred to psychiatric services on 1/31/25 and she did not see that the Resident had been referred prior to that. During an interview on 2/4/25 at 3:10 P.M., Social Work Consultant #1 said Resident #105 had been exhibiting behaviors and a care plan should have been initiated for the Resident with personalized interventions. During an interview on 2/4/25 at 4:15 P.M., Nurse #11 said she was previously the Unit Manager until mid-January 2025. She said Resident #105 had behaviors of making a racial comment to Resident #141 on 1/7/25, of yelling and throwing things. She said the Social Workers create care plans related to behavioral concerns of verbal altercations, throwing things, and substance use. During a follow up interview on 1/31/25 at 10:22 A.M., Social Work Consultant #2 said the process for the SUD counselor was for the Social Workers to tell the Administrator which residents would be seen, and the Administrator would tell the SUD Counselor. During an interview on 1/31/25 at 10:42 A.M., the Administrator said the MDS Coordinator tells the SUD Counselor which residents to see. During an interview on 1/31/25 at 10:43 A.M., the MDS Coordinator said they did not provide a list of residents to the SUD Counselor. During an interview on 1/31/25 at 10:44 A.M., the Administrator said the Assistant Administrator tells the SUD Counselor who to see and thought the list had come from the MDS Coordinator. During an interview on 1/31/25 at 10:50 A.M., the Assistant Administrator said she did not provide a list of residents to the SUD Counselor and thought the resident referrals came from the nurses or the Social Workers. During an interview on 1/31/25 at 11:34 A.M., the Assistant Administrator said she wanted to clarify that she previously had a list of residents in the facility with a history of SUD and that was why the Administrator thought she had it. She said the MDS Coordinator had run a report of residents with diagnoses related to SUD and that had been provided to the SUD Counselor the first time they had come to the facility the previous month. She said she was not sure how newly identified residents were identified for the SUD Counselor and thought maybe the Social Workers would tell the SUD Counselor. During an interview on 1/31/25 at 1:11 P.M., the SUD Counselor said he had started a contract with the facility in mid-December and had been to the facility twice, the last time about two weeks ago. He said he had been provided with a list of residents with a diagnosis of SUD in mid-December (prior to the admission of Resident #105) and had not been provided a new one. He said Resident #105 had not been referred to him for services. During an interview on 2/3/25 at 2:18 P.M., the DON said Resident #105 was sent to the hospital for a change in condition. She said the Resident had presented with stroke-like symptoms and another Resident had indicated Resident #105 had taken a controlled substance from a visitor and they were investigating this. During an interview on 2/4/25 at 4:15 P.M., Nurse #11 said she was the daytime supervisor on 2/3/25 and assisted in sending Resident #105 out to the hospital. She said the staff had found Resident #105 on 2/3/25 to be lethargic, had uneven pupils and a slight facial droop, but was still responsive. She said when emergency medical services (EMS) arrived to transport the Resident to the hospital, another Resident (#151) had said Resident #105 had taken pills from a visitor. During an interview on 2/4/25 at 2:48 P.M., Social Work Consultant #1 said he spoke with Resident #151 who said Resident #105 had taken Xanax (a Benzodiazepines that produces sedation) from a visitor on 2/3/25. He said Resident #105 had not had a Social Service Evaluation upon admission and that evaluation contained the assessment for SUD and one was never completed. He said the SUD Counselor had been at the facility on 2/3/25 and had not seen Resident #105. He said the process for the SUD Counselor was being worked on and the SUD Counselor had been provided a list of residents with a diagnosis of SUD. He said the SUD Counselor had not been provided with any additional information to indicate which residents to prioritize based on most recent use or most at risk for relapse. During an interview on 2/5/25 at 12:00 P.M., the DON said she was at the facility on 1/7/25 when Resident #105 was yelling at Resident #141. She said she was not aware that Resident #105 had used racial slurs. She said the Resident was moved diagonally across the hall and when the Resident was not de-escalating and would not take Ativan the Resident was sent to the hospital. She said no additional interventions were implemented to keep Resident #105 and Resident #141 separated and there were more interventions they could have done. During an interview on 2/5/25 at 12:00 P.M., the Administrator said facility staff did not know Resident #105 had continued to walk by the room of Resident #141 (in the same hallway) and continued to use racial slurs. He said the Social Workers should have evaluated/assessed the behaviors of Resident #105 and implemented care plans following a face-to-face assessment with resident specific interventions. He said he was unaware the Social Workers were not initiating behavioral care plans and they should be involved from a psychosocial standpoint. He said the SUD Counselor had started services at the facility approximately a month and a half prior and there had not been a system in place for the SUD Counselor referral or to prioritize the residents who were at risk or currently using substances. Refer to F745

Based on observation, interviews, and record review, the facility failed to provide social services to attain the highest practicable mental and psychological well-being for two Residents (#105 and #141), out of a total sample of 33 residents. Specifically, the facility failed 1. For Resident #105, to assess, develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder and interventions for active substance use resulting in emergency room visits; and 2. For Resident #141, to follow up after being verbally abused by Resident #105 to ensure effective interventions were implemented to prevent additional incidents of verbal abuse resulting in Resident #141 crying and verbalizing wanting to decrease socialization. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised in November 2017, indicated but was not limited to the following: -the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. -safety strategies will be implemented immediately if necessary to protect the resident and others from harm -the resident will be involved in the development and implementation of the care plan -interventions will be individualized and part of an overall care environment that supports physical functional and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities -interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. -the care plan will include, as a minimum: a description of the behavioral symptoms (frequency, intensity, duration, outcomes, location, environment, and precipitating factors or situations), targeted and individualized interventions for behavioral and/or psychosocial symptoms, rational for the interventions and approaches, specific and measurable goals for targeted behaviors, and how staff will monitor for the effectiveness of the interventions Review of the facility's policy titled Substance Use Disorder (SUD) Policy, revised February 2024, indicated but was not limited to the following: -if residents with a history of Substance Use Disorder are admitted to the facility the nursing staff will be alerted of the resident's history to ensure appropriate measures are taken if warranted -social services will refer the resident to mental health services/Licensed Drug Addiction Counselor as warranted with a focus on management of relapse risk and maintenance of sobriety -the interdisciplinary team will evaluate the resident substance use history, risk of relapse, and develop a person-centered plan of care -residents will be offered counseling from a Licensed Drug Addiction Counselor -should residents show signs of relapse, the provider will be made aware and the resident's plan of care will be revised as warranted. Review of the facility's Social Service Job Description indicated the Social Work employees had the following functions: -work with the interdisciplinary team and administration to promote and protect resident rights and the psychosocial well-being of each resident. Prevent and address abuse as mandated by law and professional licensure -complete a social history and psychosocial assessment for each resident that identifies social, emotional, and psychosocial needs -participate in the development of written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to accomplish those needs/issues, and the appropriate social worker interventions -ensure or provide therapeutic interventions to assist residents in coping with their transition and adjustment to a long term care facility, including their social, emotional, and psychological needs 1. Resident #105 was admitted to the facility in December 2024 with a new above the knee amputation of the left leg, anxiety and cannabis dependence. Review of the Minimum Data Set (MDS) assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the medical record on 1/30/25 failed to indicate a social service evaluation had been completed with Resident #105, over a month after he/she was admitted . Review of the nursing progress notes indicated on 12/31/24 Resident #105 returned to the facility at 7:00 P.M. following a personal leave with family. When the Resident returned he/she was verbally loud and noisy, making inappropriate statements to staff and slurring his/her speech. The note indicated the Resident became very agitated, threatening to punch someone if he/she did not get their medication. The Resident went to their room and started throwing around furniture, came back into the hallway swearing and exposing him/herself to the nurse, while yelling with slurred speech. 911 was called and Resident #105 was sent to the hospital. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was working on 12/31/24 when Resident #105 returned and was intoxicated. She said the Resident was yelling and swearing and there were family members of other residents around. Review of the Nurse Practitioner's (NP) Progress Note, dated 1/3/25, indicated Resident #105 was sent to the emergency room for aggressive behavior and alcohol intoxication with the following plan: -behavior: nursing to provide ongoing support to monitor for any signs of recurrent aggression or agitation and collaborate with behavioral health services if necessary -alcohol intoxication: reinforce strategies to prevent further episodes and consider behavioral counseling or substance use treatment referrals if patient agrees Review of the Social Service Note, dated 1/3/25, indicated Resident #105 was issued a 30-day discharge notice by the Social Worker, the Resident had refused to sign it and swore at the Social Worker. There were no additional notes from a Social Worker regarding the Resident being sent to the hospital on 12/31/24 related to intoxication and behaviors. Review of the nursing progress note, dated 1/7/25, indicated Resident #105 was yelling and screaming racial slurs at a new Resident (#141) and when staff attempted to redirect the Resident he/she became very aggressive and the Resident was sent to the hospital. Review of the emergency room After Visit Summary from 1/7/25 indicated Resident #105 presented with agitation and included an educational attachment for Intermittent Explosive Disorder (recurrent aggressive behavior; disordered aggression) which included treatment goals to stop outbursts through the use of cognitive behavioral therapy, group therapy, relaxation methods and medications. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called when Resident #105 was yelling racial slurs. She said the Resident was screaming, would not take Ativan (an antianxiety medication) and was sent out the hospital. During an interview on 1/30/25 at 2:10 P.M., Resident #141, who was crying, said when he/she was on their way to Rehab today Resident #105 started yelling at him/her about their music and said why are you listening to that? I don't want to hear N***** music. Resident #141 said he/she had previous encounters with Resident #105 using racial slurs. During an interview on 1/30/25 at 2:42 P.M., the Director of Nurses (DON) said on 1/7/25 Resident #105 was yelling and did not want a roommate and Resident #105's room was changed to diagonally across the hall. She said there had been a few issues with Resident #105 since admission and Resident #105 had a history of drug and alcohol abuse. Review of the medical record for Resident #105 on 1/30/25 failed to address behaviors of yelling, swearing, being aggressive, saying racial slurs, or substance abuse and failed to identify interventions. The record review indicated the only Social Service progress note was written on 1/3/25 when the 30-day discharge notice was given. There were no additional notes or assessments from a Social Worker. During an interview on 1/31/25 at 9:40 A.M., Social Worker #1 said when residents were first admitted the process was for a Social Worker to complete the Social Service Evaluation which included but was not limited to a social history, a trauma assessment, and a SUD assessment. She said assessments were usually completed within one week of admission. She reviewed the medical record for Resident #105 and said a Social Service Evaluation had not been completed. She said Resident #105 has had behaviors of yelling, screaming, using racial slurs and had been sent out to the hospital for being intoxicated. She said she did not know the Resident was also sent to the hospital on 1/7/25 related to behaviors. Social Worker #1 said the facility Social Workers do not create or participate in care plans related to behavioral concerns. She said she verbally referred residents to the psychiatric clinicians and she could not recall if she ever referred Resident #105. She said the facility had recently contracted with a Substance Use Disorder (SUD) Counselor and she was not sure how the residents were referred to the SUD counselor. She said the interdisciplinary team discussed Resident #105 at morning meeting on Monday 1/27/25, possibly related to smoking and the nursing staff was going to refer the Resident to the psychiatric services. Review of the paper record indicated Resident #105 had consented to be seen by the contracted psychiatric services on 12/24/24. Review of the contracted psychiatric services referral book on 1/31/25 failed to indicate Resident #105 had been referred for services. Review of the medical record failed to indicate Resident #105 had been seen by psychiatric services. During an interview on 1/31/25 at 9:40 A.M., Social Work Consultant #2 said the Social Workers do not create or participate in care plans or interventions related to behavioral concerns. She said Resident #105 has had behaviors of yelling, swearing and being verbally aggressive. She said the Resident can be combative in discussions and was screaming and swearing at her on 1/30/25 when she inquired if the Resident would change his/her room. She said she was not sure how the residents were referred to the SUD Counselor and would follow up with the surveyor. During an interview on 2/4/25 at 12:11 P.M., Unit Manager #1 said she was a nurse on the unit prior to becoming the Unit Manager last week. She said the behavioral care plans were usually a collaboration between the Social Workers and the Unit Manager. She said she was not sure if behavioral interventions were implemented for Resident #105. During an interview on 2/4/25 3:10 P.M., Social Work Consultant #1 said Resident #105 had been exhibiting behaviors and personalized interventions should have been initiated. During an interview on 2/4/25 at 4:15 P.M., Nurse #11 said she was previously the Unit Manager until mid-January 2025. She said Resident #105 had behaviors of making a racial comment to Resident #141 on 1/7/25, of yelling and throwing things. She said the Social Workers create care plans related to behavioral concerns of verbal altercations, throwing things and substance use. During an interview on 1/31/25 at 11:34 A.M., the Assistant Administrator said the MDS Coordinator had run a report of residents with diagnoses related to SUD and that had been provided to the SUD Counselor the first time they had come to the facility the previous month. She said she was not sure how newly identified residents were identified for the SUD Counselor and thought maybe the Social Workers would tell the SUD Counselor. During an interview on 1/31/25 at 1:11 P.M., the SUD Counselor said he had started a contract with the facility in mid-December and had been to the facility twice, the last time about two weeks ago. He said he had been provided a list of residents with a diagnosis of SUD in mid-December (prior to the admission of Resident #105) and had not been provided a new one. He said Resident #105 had not been referred to him for services. During an interview on 2/3/25 at 2:18 P.M., the DON said Resident #105 was sent to the hospital for a change in condition. She said the Resident had presented with stroke-like symptoms and another Resident had indicated Resident #105 had taken a controlled substance from a visitor and they were investigating this. During an interview on 2/4/25 at 4:15 P.M., Nurse #11 said she was the daytime supervisor on 2/3/25 and assisted in sending Resident #105 out to the hospital. She said the staff had found Resident #105 on 2/3/25 to be lethargic, had uneven pupils and a slight facial droop, but was still responsive. She said when emergency medical services (EMS) arrived to transport the Resident to the hospital, another Resident (#151) had said Resident #105 had taken pills from a visitor. During an interview on 2/4/25 at 2:48 P.M., Social Work Consultant #1 said he spoke with Resident #151 who said the Resident #105 had taken Xanax (a Benzodiazepines that produces sedation) from a visitor on 2/3/25. He said Resident #105 had not had a Social Service Evaluation upon admission and that evaluation contained the assessment for Substance Use Disorder and one was never completed. He said the SUD Counselor had been at the facility on 2/3/25 and had not seen Resident #105. He said the process for the SUD Counselor was being worked on and the SUD had been provided a list of residents with a diagnosis of SUD. He said the SUD had not been provided with any additional information to indicate which residents to prioritize based on most recent use or most at risk for relapse. During an interview on 2/5/25 at 12:00 P.M., the Administrator said the Social Workers should have evaluated/assessed the behaviors of Resident #10 with a face-to-face assessment to obtain resident specific interventions. He said he was unaware the Social Workers were not initiating behavioral care plans and they should be involved from a psychosocial stand point. He said the SUD Counselor had started services at the facility approximately a month and a half prior and there had not been a system in place for the SUD Counselor referral or to prioritize the residents who were at risk or currently using substances. 2. Resident #141 was admitted to the facility in January 2025 for short term rehabilitation and was receiving physical and occupational therapy services. Review of the MDS assessment, dated 1/13/25, indicated Resident #141 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact. During an interview on 1/30/25 at 2:10 P.M., Resident #141, who was crying, said when he/she was on their way to Rehab today Resident #105 started yelling at him/her about their music and said why are you listening to that? I don't want to hear N***** music. Resident #141 said he/she had previous encounters with Resident #105 using racial slurs. Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs. During an interview on 1/30/25 at 2:40 P.M., Nurse #3 said she had been working on 1/7/25 when Resident #105 called Resident #141 a nxxxxx and said Resident #141 was making the room smell like a zoo. She said Resident #141 was so upset that he/she started crying because of the racial slurs that were hurled at him/her by Resident #105. Nurse #3 said she notified Nurse #1 who was the nursing supervisor. During an interview on 1/30/25 at 2:55 P.M., Nurse #1 said she was the supervisor on 1/7/25 and was called down to the unit to assist as Resident #105 was yelling about Resident #141 saying that he/she smelled and was calling the Resident the N word. She said the plan at that time was to split up the two residents right way and moved Resident #105 across the hall. She said on 1/7/25, Resident #141 was very sensitive about this and was crying. She said another verbal altercation was bound to happen between the two residents. During an interview on 1/30/25 at 2:42 P.M., the DON said she was aware Resident #105 had used racial slurs towards Resident #141 today on the way to attend physical therapy together and the staff were working on a plan to keep the residents separated. She said Resident #105 previously had a verbal altercation with Resident #141 when Resident #141 was admitted to the facility and a room change was initiated. Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall. During an interview on 1/31/25 at 9:40 A.M., Social Worker #1 said she was at the facility on 1/7/25 when Resident #105 was yelling at Resident #141. She said she had not directly heard the racial slurs, but staff had told her. She said she met with Resident #141 at that time and the Resident was crying. She said she invited Resident #141 to sit in her office the next day as the Resident was walking by and the Resident talked about how sad he/she was about the racial slur. She said she had not checked with Resident #141 on the effectiveness of the intervention of moving Resident #105 diagonally across the hall. During an interview on 1/31/25 at 9:45 A.M., Social Work Consultant #2 said she met with Resident #141 following the verbal abuse on 1/30/25 and Resident #141 told her the racial comments had been happening every day. During an interview on 2/3/25 at 1:30 P.M., Social Worker #1 said the facility staff did not pay enough attention to Resident #141 and Resident #105 following the verbal altercation on 1/7/25. During an interview on 2/5/25 at 12:00 P.M., the DON said no additional interventions were implemented following the verbal abuse on 1/7/25 to keep Resident #105 and Resident #141 separated and there were more interventions they could have done. During an interview on 2/5/25 at 12:00 P.M., the Administrator said facility staff did not know Resident #105 had continued to walk by the room of Resident #141 (in the same hallway) and continued to use racial slurs. He said the Social Workers should have followed up with Resident #141 to determine if there had been any further interactions with Resident #105.

Based on observations, interviews, record review, and policy review, the facility failed to ensure four Residents (#4, #2, #110, and #117), out of a total sample of 35 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #4, to implement and complete treatments as ordered for: a. Site #8-Stage 2 Pressure Wound (partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed, without slough (yellow/white material in wound bed) or an intact, open, or ruptured blister) of the Right Buttock, b. Site #9-Non-Pressure Wound Sacrum (area at the lower spine) (MASD-Moisture Associated Skin Damage-caused by prolonged exposure to various sources of moisture including urine or stool, perspiration, wound exudate (drainage), mucus, saliva, and their contents) that progressed to a Stage 3 Pressure Wound (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss), c. Site #10-Unstageable (due to necrosis) (pressure ulcer known but is not stageable due to coverage of the wound bed by slough or eschar (dead tissue typically brown, tan, or black and may be crusty) of the Right Lateral Foot and failed to implement effective pressure relieving interventions by off-loading heels/feet, d. Site #12-Stage 3 Pressure Wound of the Left Buttock, and e. Site #14-Stage 3 Pressure Wound of the Left Buttock; and 2. For Resident #2, to implement and complete treatments as ordered for a stage 4 pressure injury (full thickness skin loss extending through the fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place) with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement) to the coccyx (bone at the end of the spine); 3. For Resident #110, to address wound physician's recommendations timely for care and treatment of a stage 4 pressure injury to the coccyx; and 4. For Resident #117, to implement and complete treatments as ordered to a stage 3 pressure ulcer on the coccyx and to implement an effective pressure relieving intervention. Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018 indicated but was not limited to the following: -Risk Factors that increase a resident's susceptibility to develop or not to heal Pressure Ulcer/Pressure Injury (PU/PI) include but are not limited to: Impaired/decreased mobility, the presence of previously healed pressure ulcers/injuries (areas of healed stage 3 or 4 PU/PI are more likely to have recurrent breakdown), exposure of skin to urinary or fecal incontinence, and co-morbid conditions, such as end stage renal disease or diabetes. -If a new skin alteration is noted, initiate a pressure/non pressure form related to the type of alteration noted. -The following information should be recorded in the resident's medical record utilizing facility forms: the condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified; documentation in the medical record addressing Physician notification if new skin alteration noted with change of plan of care, if indicated. Review of the facility's policy titled Prevention of Pressure Ulcers/Injury, dated as last revised 11/2017, indicated but was not limited to the following: -Assess the resident on admission for existing PU/PI risk factors. Repeat the risk assessment weekly and upon changes in condition. -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). -Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) -Reposition resident as indicated on the care plan. -Keep the skin clean and free of exposure to urine and fecal matter. -At least every two hours, reposition residents who are reclining or dependent on staff for repositioning. -Provide support devices and assist as needed. -Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of the facility's policy titled Dressings, Dry/Clean, dated 4/2018, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. -Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. -Check the treatment record. 1. Resident #4 was admitted to the facility in January 2010, and recently readmitted in January 2024 with diagnoses including morbid obesity, diabetes mellitus with diabetic polyneuropathy (symptoms of numbness, weakness, and decreased sensation usually starting in feet/hands), and peripheral vascular disease (PVD-narrowing of blood vessels causing decreased blood flow). Review of the Minimum Data Set (MDS) assessment, dated 3/27/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #4 had skin treatments and was dependent on staff for assistance with positioning. Review of the comprehensive care plan indicated but was not limited to the following: FOCUS: Resident has incontinence related to decreased motivation to toilet and weakened bladder tone. GOAL: Resident will remain free from skin breakdown due to incontinence. INTERVENTIONS: Brief Use for containment and dignity; Incontinent care and apply barrier cream with incontinent care. FOCUS: Resident has a self-care deficit related to decreased motivation and obesity. INTERVENTIONS: Bed Mobility and Positioning-Totally dependent; Turning and Repositioning every two hours and as needed. FOCUS: Resident has potential for pressure ulcer development related to disease process, history of ulcers, immobility, obesity, diabetes, and incontinence. GOAL: Resident will not develop any new areas of skin breakdown. INTERVENTIONS: Administer preventative skin care as ordered. FOCUS: Pressure Ulcer: Ulceration or interference with structural integrity of layers of skin. GOAL: Show no signs of infection through review date; Show reduction in size/stage of pressure ulcer. INTERVENTIONS: Consult and treatment by Certified Wound Doctor or Certified Wound Nurse as needed (PRN), monitor for changes and update provider, offload heels as tolerated when in bed, offload wounds as tolerated, treatments as ordered, and turn/reposition as needed. Review of the medical record indicated Resident #4 was followed by a Wound Care Physician at the facility. a. Site #8-Stage 2 Pressure Wound of the Right Buttock. Review of the weekly skin check, dated 12/4/23, indicated a shearing area to the coccyx (area at the base of spine-just below the sacrum) with a treatment in progress; there was no indication of a right buttock wound. Review of the Wound Evaluation and Management Summary, dated 12/5/23, indicated but was not limited to the following: - Site #8-Stage 2 Pressure Wound of the Right Buttock measured 3 x 2 centimeters (cm) depth was not measurable due to presence of tissue overgrowth with light serous drainage (pale yellow/transparent drainage). Duration: over three days -Recommendation: Silver sulfadiazine (antimicrobial cream to prevent infection) and calcium alginate (antibacterial product for wound drainage), cover with gauze island border twice daily. Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 12/6/23. Review of the Wound Evaluation and Management Summary, dated 12/19/23, indicated but was not limited to the following: - Site #8-Stage 2 Pressure Wound of the Right Buttock measured 2 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at Goal. -Recommendation: Apply Collagen powder (wound filler to aid in formation of healthy tissue) once daily and cover with gauze island border twice daily. Review of the Treatment Administration Record (TAR) failed to indicate the order was obtained for the new treatment. The previous order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 12/26/23, indicated but was not limited to the following: - Site #8-Stage 2 Pressure Wound of the Right Buttock measured 3 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at Goal. -Recommendation: Apply Collagen powder once daily and cover with gauze island border twice daily. Review of the TAR indicated the order was obtained for the new treatment (7 days after the initial recommendation on 12/19/24). Further review of the December 2023 TAR indicated the treatments were not signed off as administered 7 out of 53 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/16/24, indicated but was not limited to the following: - Site #8-Stage 2 Pressure Wound of the Right Buttock measured 0.5 x 0.7 x 0.1 cm with light serous drainage. Wound Progress: Not at Goal. -Recommendation: Silver sulfadiazine and cover with gauze island border twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment. The order did not contain a dressing as recommended by the wound physician. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. The Resident was hospitalized from 1/18/24-1/26/24. Further review of the January 2024 TAR indicated the treatments were not signed off as administered 7 out of 47 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/31/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 7 x 3 x 0.1 cm with light serous drainage. Wound Progress: Exacerbated due to recent hospitalization . -Recommendation: Collagen sheet with silver and cover with gauze island border twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment. The order for Silver Sulfadiazine remained in effect, still with no dressing as recommended on 1/16/24 from the Wound Physician. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/8/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 3 x 3.5 x 0.1 cm with moderate serous drainage. -Recommendation: Santyl (debriding agent to rid the wound of necrotic (dead) tissue and aid in healing) and calcium alginate once daily and cover with gauze island border twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment. The order for Silver Sulfadiazine remained in effect, still with no dressing as recommended on 1/16/24 from the Wound Physician. On 2/12/24 an order was written for Santyl to the right buttock once daily. The order failed to include the calcium alginate or the dressing. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/13/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 2 x 1.5 x 0.1 cm with light serous drainage. -Recommendation: calcium alginate once daily, silver sulfadiazine twice daily and cover with gauze island border twice daily. The entire order was written to be changed twice daily on 2/14/24. Review of the Wound Evaluation and Management Summary, dated 2/20/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 1.5 x 1 x 0.1 cm with light serous drainage. -Recommendation: silver sulfadiazine and cover with gauze island border twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment per the wound doctor's recommendations. The previous order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the February 2024 TAR indicated the treatments were not signed off as administered 3 out of 57 opportunities. Review of the Wound Evaluation and Management Summary, dated 3/1/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 1.5 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at Goal. -Recommendation: silver sulfadiazine and cover with gauze island border twice daily. The order was written on 3/4/24. (14 days after the initial recommendation was made.) Further review of the March 2024 TAR indicated the treatments were not signed off as administered 7 out of 62 opportunities. Review of the Wound Evaluation and Management Summary, dated 4/9/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 2 x 1 x depth is unmeasurable due to tissue overgrowth with light serous drainage. Wound Progress: Not at Goal. -Recommendation: Collagen sheet with silver (advanced dressing for management of wounds to reduce/prevent infection) once daily cover with gauze island border twice daily. The order was obtained as recommended by the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/16/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock measured 1.4 x 1.2 x 0.05 cm. -Recommendation: Collagen sheet with silver cover with gauze island border daily. The order was obtained as recommended by the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated but was not limited to the following: - Site #8-Stage 3 Pressure Wound of the Right Buttock-RESOLVED Further review of the April 2024 TAR indicated the treatments were not signed off as administered 6 out of 47 opportunities. b. Site #9-Non-Pressure Wound Sacrum (MASD). Review of the weekly skin check, dated 12/4/23, indicated a shearing area to the coccyx with a treatment in progress. Review of the nursing and physician progress notes failed to indicate the area on the coccyx was reported to the physician. Review of the physician's orders/TAR failed to indicate an order for a treatment to the coccyx. Review of the Wound Evaluation and Management Summary, dated 12/5/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 3 x 1 cm x depth not measurable due to tissue overgrowth, open ulceration with light serous drainage. Duration over three days. -Recommendation: Apply Silver sulfadiazine and calcium twice daily, cover with gauze island border dressing. The new area identified on the 12/4/23 weekly skin check as shearing of the coccyx by the nurse, did not have a treatment in place at the time of the skin check, nor was one implemented when the area was discovered. The area was evaluated by the Wound Physician on 12/5/23 and determined to be MASD of the sacrum. Review of the TAR indicated the order was implemented on 12/6/23. Review of the Wound Evaluation and Management Summary, dated 12/19/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1 x 1 x 0.1 cm, open areas with exposed dermis (middle layer of skin). -Recommendation: Apply Collagen powder daily, cover with gauze island border dressing twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment as recommended. The order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 12/26/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1 x 0.5 x 0.1 cm, open areas with exposed dermis. -Recommendation: Apply Collagen powder daily, cover with gauze island border dressing twice daily. Review of the TAR indicated the order was implemented on 12/27/23 as follows: Sacrum-Cleanse with wound cleanser, pat dry, apply skin prep (forms a barrier between skin and adhesive to help preserve skin integrity) to surrounding skin, apply collagen powder to wound bed and cover with gauze island border dressing twice daily. (8 days after it was recommended) Further review of the December 2023 TAR indicated the treatments were not signed off as administered 7 out of 53 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/16/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1.5 x 0.5 x 0.1 cm, open areas with exposed dermis. Wound Progress: Not at goal. -Recommendation: Apply silver sulfadiazine and cover with gauze island border dressing twice daily. Review of the TAR indicated the order was implemented on 1/17/24 as follows: silver sulfadiazine apply to sacrum topically twice daily. No dressing was ordered as recommended to cover the wound. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of a dressing to cover the wound. The Resident was hospitalized from 1/18/24-1/26/24. Further review of the January 2024 TAR indicated the treatments were not signed off as administered 6 out of 45 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/31/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1.5 x 0.4 x 0.1 cm, open areas with exposed dermis. Wound Progress: Not at goal. -Recommendation: Apply Collagen Sheet with and cover with gauze island border dressing twice daily. Review of the TAR failed to indicate an order was obtained for the collagen sheet with silver treatment as recommended. The order for silver sulfadiazine remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/8/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) was exacerbated and was now a Stage 3 Pressure Wound and measured 1.5 x 2 x 0.1 cm with moderate serous drainage. -Recommendation: Apply followed by calcium alginate and cover with gauze island border dressing daily. Review of the TAR failed to indicate an order was obtained for the Santyl and calcium alginate treatment as recommended. An order was written for Santyl Ointment-Apply to sacrum topically every day for wound care on 2/12/24. The order failed to contain the calcium alginate or a dressing to cover the wound. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/13/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 6 x 2 x 0.1 cm with moderate serous drainage. Wound Progress: Not at Goal. -Recommendation: Apply Calcium Alginate once daily and silver sulfadiazine twice daily cover with gauze island border dressing twice daily. The order was written as follows: Cleanse wound with wound cleanser, apply silver sulfadiazine to wound bed, apply calcium alginate then cover with gauze island border dressing twice daily. Review of the Wound Evaluation and Management Summary, dated 2/20/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Silver sulfadiazine twice daily cover with gauze island border dressing twice daily. -Skin substitute (alternative to a skin graft used to aid in healing of wounds not responding to typical treatment) wound candidate evaluation. Review of the TAR failed to indicate the silver sulfadiazine treatment as recommended. The previous order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the February 2024 TAR indicated treatments were not signed off as administered 4 out of 57 opportunities. Review of the Wound Evaluation and Management Summary, dated 3/1/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: Silver sulfadiazine apply once weekly. If dressing falls off use silvadene and a border gauze daily. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The order from 2/13/24 was still in effect as it was not changed on 2/20/24 as recommended or on 3/1/24 as recommended. An order for silver sulfadiazine and cover with gauze island border twice daily was written on 3/4/24, also not per the recommendation made on 3/1/24 by the wound physician, the instructions pertaining to the skin substitute and full dressing were not included in the order. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 3/8/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1.5 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Xeroform gauze once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The previous incorrect order from 3/4/24 remained in effect until 3/11/24. On 3/11/24 orders were written as follows: -Maintain dressing to sacrum area, if dressing falls off apply the as needed (PRN) treatment of silver sulfadiazine with border gauze daily. -Cleanse area to sacrum wound with wound cleanser, apply silver sulfadiazine to wound followed by border gauze daily PRN if dressing falls off. The incorrect order from 3/4/24 remained in effect until 3/11/24, therefore the newly applied skin substitute graft from 3/8/24 was disturbed that evening and the wrong treatment continued until 3/11/24, when an order was written to maintain the sacrum dressing (which had already been disturbed) and therefore should have had daily dressing changes until the next wound physician visit and it did not. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 3/19/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 4 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Collagen sheet with silver apply once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. On 3/20/24 orders were written as follows: -Maintain dressing to sacrum area, if dressing falls off apply the PRN treatment of collagen sheet with silver followed by border gauze daily. Every shift for sacrum dressing. -Maintain restorigin/border gauze dressing to sacrum until wound MD in to re-evaluate, check placement every shift. If soilage is noted to the border gauze, change the border gauze as needed (see PRN order) if entire dressing falls off, refer to PRN collagen sheet with silver every shift for sacrum wound. Review of the TAR failed to indicate an order for if dressing falls of use silverdene and border gauze daily. The order was written for a collagen sheet with silver followed by a border gauze daily. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the March 2024 TAR indicated treatments were not signed off as administered 6 out of 21 opportunities. Review of the Wound Evaluation and Management Summary, dated 4/9/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Collagen sheet with silver apply once weekly. For the week of 4/15 apply Collagen AG and a border gauze once daily. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The incorrect orders written 3/20/24 remained in effect. The additional order for the week of 4/15/24 as indicated above was not written until 4/17/24 and initiated on 4/18/24. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Collagen sheet with silver apply once weekly. Calcium Alginate once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The order was written for daily dressing changes as follows: Cleanse area to sacrum wound with wound cleanser, pat dry, apply skin prep to surrounding skin, apply collagen AG sheet with silver and calcium alginate sheet to wound followed by a border gauze dressing every day shift for wound care. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1.2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Collagen sheet with silver apply once weekly. Hydrocolloid sheet (satin) (moisture-retentive dressing with gel properties and waterproof to isolate the wound from bacteria contaminants) once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The orders written included the gauze island border dressing and not the hydrocolloid sheet. The order written 5/1/24 read as follows: -Maintain the Restorigin/Border gauze dressing to sacrum wound until Wound MD in to re-evaluate, check placement every shift. If soilage is noted to the border gauze change the border gauze as needed (see PRN order). If entire dressing falls off, refer to PRN Collagen sheet with silver every shift for sacrum wound. Review of the TAR indicated the wound descriptors including the drainage amount/type and wound bed. These descriptors were documented on daily basis, indicated the wound bed was exposed and assessed daily. Additionally, the PRN order to change the dressing for soilage and the PRN order if the entire dressing falls off were not signed off as administered. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the April 2024 TAR indicated treatments were not signed off as administered 3 out of 13 opportunities. Review of the Wound Evaluation and Management Summary, dated 5/7/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1.1 x 0.7 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Collagen sheet with silver apply once weekly. Hydrocolloid sheet (satin) once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The incorrect order from 5/1/24 remained in effect. Review of the TAR indicated the wound descriptors including the drainage amount/type and wound bed. These descriptors were documented on daily basis, indicated the wound bed was exposed and assessed daily. Additionally, the PRN order to change the dressing for soilage and the PRN order if the entire dressing falls off were not signed off as administered. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1 x 0.7 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Calcium Alginate once weekly. Collagen sheet with silver apply once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary dressing: Hydrocolloid sheet (satin) apply three times weekly. Rev[TRUNCATED]

Based on interviews, record review, and policy review, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for three Residents (#36, #34, and #4), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #36, to provide proper care and treatment of a non-pressure right heel wound including accurately implementing the Wound Consultant's recommendations; 2. For Resident #4, to implement and complete treatments as ordered for: a. Site #9-Non-Pressure Wound Sacrum (Moisture Associated Skin Damage-MASD), resulting in the wound progressing to a Stage 3 pressure ulcer, b. Site #11-Non-Pressure Wound of the Right Thigh (trauma/from brief), c. Site #13-Skin Tear of the Right Shin, d. Site #15-Non-Pressure Wound of the Right Buttock (MASD), and e. Site #16-Non-Pressure Wound of the Right Thigh (trauma/from brief); and 3. For Resident #34, to ensure weekly weights were obtained for the management of congestive heart failure (CHF- progressive heart disease that affects pumping action of the heart muscles which leads to fatigue, shortness of breath). Findings include: 1. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: - If a new skin alteration is noted, initiate a pressure/non-pressure form related to the type of alteration noted. - The following information should be recorded in the resident's medical record utilizing facility forms: the condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified; documentation in the medical record addressing Physician notification if new skin alteration noted with change of plan of care, if indicated. Resident #36 was admitted to the facility in August 2022 with diagnoses including morbid obesity and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 4/9/24, indicated Resident #36 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #36 required assistance from staff to perform activities of daily living, including but not limited to bed mobility and transfers. The MDS also indicated Resident #36 was at risk for alteration in skin. During an observation with interview on 5/20/24 at 12:30 P.M., the surveyor observed Resident #36 resting in bed, lying on his/her back. Resident #36 said he/she has an area to his/her right heel which opens and closes frequently. Resident #36 said he/she had a traumatic injury to his/her right heel several years ago when this all started. The surveyor did not observe a dressing on Resident #36's right heel. Review of Resident #36's Physician's Orders indicated the following: - 2/23/23: Weekly Skin Assessment by Licensed Nurse, every Friday day shift. Review of the Weekly Skin Evaluation assessment, dated 3/27/24, indicated Resident #36 had a right heel area open with treatment in place. Further review of the Weekly Skin Evaluation assessments continued to indicate Resident #36 had a right heel area on 4/7/24, 4/15/24, 4/22/24, 4/29/24, 5/6/24, and 5/14/24. Review of the Resident #36's Physician's Orders, in place from 3/6/23 to 4/1/24, indicated: - Skin prep bilateral heels every shift every day for prevention. Review of the medical record from 3/27/24 through 4/9/24 failed to indicate treatment orders addressing Resident #36's open non-pressure right heel wound. Review of the Wound Consultant's notes, dated 4/9/24, indicated the following: - Resident #36 had a non-pressure wound of right heel, partial thickness with an etiology of trauma/injury. - The objective of the Wound Consultant treatment was to manage exudate (drainage) and maintain healing. - The wound duration was noted to be greater than 3 days. - Wound size: 1.5 centimeters (cm) x 1.0 cm x not measurable depth due to presence of tissue overgrowth. The total surface area of the wound was 1.5 cm squared. The wound has light serous (clear) drainage. - Dressing treatment plan: collagen sheet with silver, gauze island border dressing changed once daily. Review of Physician's Orders following the Wound Consultant visit on 4/9/24, failed to indicate treatment orders were put in place for the open non-pressure right heel wound based on the recommendations made during the visit. Review of the Wound Consultant's notes, dated 4/16/24, indicated the following: - Resident #36 had a non-pressure wound of right heel, full thickness with an etiology of trauma/injury. - The objective of the Wound Consultant treatment was to maintain healing. - The wound duration was noted to be greater than 10 days. - Wound size: 2.5 cm x 2.0 cm x 0.05 cm with a total surface area of 5.00 cm squared. The wound had moderate serosanguinous (bloody) drainage. The wound bed contained 50% slough (necrotic (dead) tissue that is green, yellow, tan, or brown, and may be moist, loose, or stringy) and 50% granulation (healthy) tissue. - Wound progress was noted to be not at goal. - Dressing treatment plan: collagen sheet with silver, gauze island border dressing and skin prep to surrounding skin once daily. Review of the Physician's Orders following the Wound Consultant visit on 4/16/24, indicated treatment orders for the non-pressure right heel wound were put in place as recommended by the Wound Consultant on 4/17/24, 21 days after the non-pressure right heel wound was identified. Review of the Wound Consultant's notes, dated 4/30/24, indicated the following: - Resident #36 had a non-pressure wound of right heel, full thickness with an etiology of trauma/injury. - The wound duration was noted to be greater than 38 days. - Wound size: 3.5 cm x 2.0 cm x not measurable due to presence of tissue overgrowth. The total surface area of the non-pressure right heel wound was 7.00 cm squared. The wound had light serosanguinous drainage. The wound bed contained 100% granulation tissue. - Dressing treatment plan: collagen sheet with silver, gauze island border dressing and skin prep to surround skin once daily. Review of the Wound Consultant's notes indicated the non-pressure right heel wound progress was not at goal. The non-pressure right heel wound surface area grew from 5.00 cm squared on 4/16/24 to 7.00 cm squared on 4/30/24 (total increase in surface area of 2.00 cm squared). Review of Wound Consultant notes from 5/7/24, indicated the non-pressure right heel wound progress was improved as evidenced by decreased surface area (3.00 cm squared) and physician's orders including treatment recommendations for collagen sheet with silver, gauze island border dressing with skin prep to surrounding skin once daily were in place. Review of the Wound Consultant's notes, dated 5/14/24, indicated the following: - Resident #36 had a non-pressure wound of right heel, full thickness with an etiology of trauma/injury. - Objective of the Wound Consultant treatment was to maintain healing. - The wound duration was noted to be greater than 38 days. - Wound size: 1.0 cm x 1.0 cm x not measurable due to presence of tissue overgrowth. The total surface area of the non-pressure right heel wound was 1.00 cm squared. The wound had light serous drainage. The wound bed contained 100% granulation tissue. - Dressing treatment plan: collagen sheet with silver, gauze island border dressing and skin prep to surrounding skin once daily. Review of Physician's Orders following the Wound Consultant's visit on 5/14/24, failed to include the collagen sheet with silver as recommended for the open non-pressure right heel wound. Further review of the medical record failed to indicate why the recommendation for the collagen sheet with silver was left off the active physician's order. Review of the Treatment Administration Record (TAR) failed to include collagen sheet with silver as the active treatment order for Resident #36 after 5/15/24 as recommended by the Wound Consultant. During an interview on 5/21/24 at 8:32 A.M., Unit Manager (UM) #1 said the Wound Consultant comes in once a week, typically either Tuesday or Friday. UM #1 said typically Nurse #5 completes wound rounds with the Wound Consultant unless they are unavailable. During an interview on 5/21/24 at 12:43 P.M., Nurse #5 said she completes weekly wound rounds with the Wound Consultant and updates the medical record based on her recommendations. Nurse #5 said she will clarify recommendations with the resident's MD/NP and update the orders as needed. Nurse #5 said Resident #36 had an old traumatic injury to the right heel before entering the facility. Nurse #5 said the area to the right heel tends to re-open frequently and requires intervention to heal due to the area being fragile. Nurse #5 said she was not certain when Resident #36's non-pressure right heel wound re-opened. Nurse #5 reviewed the medical record for Resident #36 and said the Wound Consultant recommended a treatment of collagen sheet with silver, gauze border island dressing and skin prep to the surrounding skin on 5/14/24. Nurse #5 said the current active physician's order for Resident #36 did not include a collagen sheet with silver, but all collagen sheets in the facility included silver. On 5/21/24 at 2:25 P.M., the surveyor observed the following: - Nurse #6 gathered wound supplies from the treatment cart (including barrier paper, non-sterile 4x4 gauze pads, normal saline, collagen sheet and gauze island border dressing) at the door of Resident #36's room and set up on the overbed table after wiping it down with bleach. - Unit Manager #1 entered the room, donned gloves, and assisted Resident #36 in lifting his/her right leg off the bed. - Nurse #6 cleaned the wound bed with normal saline wash and patted it dry with gauze. - Nurse #6 placed the collagen sheet over the wound on the right heel. - Nurse #6 covered the area with the gauze island border dressing. During an interview on 5/21/24 at 2:36 P.M., Nurse #6, UM #1 and the surveyor reviewed the collagen sheet packaging which failed to indicate the collagen sheet had silver. UM #1 said the collagen sheet placed on Resident #36 during the dressing change did not have silver in it as per the Wound Consultant's recommendation from 5/15/24. UM #1 said the collagen sheet with silver is in a different packaging. UM #1 reviewed the Wound Consultant's recommendations from 5/15/24 and said the order should include collagen sheet with silver. During an interview on 5/21/24 at 2:48 P.M., UM #1 said when a resident has a new skin area identified, the MD/NP should be notified, and any orders given should be put into the medical record. UM #1 said the nurse would then document in a note the changes identified in the resident's skin. UM #1 and the surveyor reviewed the medical record for Resident #36. UM #1 said there was no nursing note documentation from 3/27/24 for Resident #36's non-pressure right heel wound, but there should be. UM #1 said Resident #36 was not seen by the Wound Consultant until 4/9/24. UM #1 said the first order put into the medical record related to the treatment of Resident #36's non-pressure right heel wound was on 4/17/24. UM #1 said she would not expect there to be that kind of delay in treatment. During an interview on 5/22/24 at 10:48 A.M., NP #1 said recommendations from the Wound Consultant are reviewed by the providers. NP #1 said Wound Consultant recommendations would be approved for treatment unless there were any issues in which they would document the need for the change. During an interview on 5/22/24 at 11:43 A.M., the Director of Nursing (DON) said when a new skin area or re-opened skin area is found on a resident the nurse would notify the MD/NP for treatment orders. The DON said the resident's profile would also be updated to identify the need for the Wound Consultant to follow the area. The DON said the Wound Consultant follows any resident in the facility with open skin issues/concerns. The DON said once the Wound Consultant sees the resident, any recommendations would be reconciled with the MD/NP and put in place for treatment. The DON and the surveyor reviewed the findings as related to Resident #36. The DON said Resident #36 should not have gone without a treatment to an open area to the right heel. The DON said skin prep to an open area was not an appropriate treatment. The DON said orders should be reconciled based on the recommendations given by the Wound Consultant. The DON said the orders for Resident #36 needed to be reconciled again with the MD/NP for not being accurate. During an interview on 5/22/24 at 3:11 P.M., the Wound Consultant said she typically comes into the facility on a weekly basis. The Wound Consultant said Nurse #5 typically completes wound rounds with her, but if she is unavailable the Unit Managers are available to complete rounds. The Wound Consultant said she will assess the wound, update the nurse regarding the status of the wound and make any treatment recommendations. The Wound Consultant said the current order for Resident #36 should include a collagen sheet with silver. The Wound Consultant said she was not updated regarding Resident #36 receiving a treatment without the collagen sheet. 48084 2. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018 indicated but was not limited to the following: -If a new skin alteration is noted, initiate a pressure/non pressure form related to the type of alteration noted. -The following information should be recorded in the resident's medical record utilizing facility forms: the condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified; documentation in the medical record addressing Physician notification if new skin alteration noted with change of plan od care, if indicated. Resident #4 was admitted to the facility in January 2010, and recently readmitted in January 2024 with diagnoses including morbid obesity, diabetes mellitus with diabetic polyneuropathy (symptoms of numbness, weakness, and decreased sensation usually starting in feet/hands), and peripheral vascular disease (PVD-narrowing of blood vessels causing decreased blood flow). Review of the MDS assessment, dated 3/27/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the BIMS. Additionally, Resident #4 had skin treatments and was dependent on staff for assistance with positioning. Review of the comprehensive care plan indicated but was not limited to the following: FOCUS: Resident has incontinence related to decreased motivation to toilet and weakened bladder tone. GOAL: Resident will remain free from skin breakdown due to incontinence. INTERVENTIONS: Brief Use for containment and dignity; Incontinent care and apply barrier cream with incontinent care. FOCUS: Resident has a self-care deficit related to decreased motivation and obesity. INTERVENTIONS: Bed Mobility and Positioning-Totally dependent; Turning and Repositioning every two hours and as needed. FOCUS: Resident has potential for pressure ulcer development related to disease process, history of ulcers, immobility, obesity, diabetes, and incontinence. GOAL: Resident will not develop any new areas of skin breakdown. INTERVENTIONS: Administer preventative skin care as ordered. Review of the medical record indicated Resident #4 was followed by a Wound Care Physician at the facility. a. Site #9-Non-Pressure Wound Sacrum (area at the lower spine) (MASD-caused by prolonged exposure to various sources of moisture including urine or stool, perspiration, wound exudate (drainage), mucus, saliva, and their contents). Review of the weekly skin check, dated 12/4/23, indicated a shearing area to the coccyx (area at the base of spine-just below the sacrum) with a treatment in progress. Review of the nursing progress notes failed to indicate the area on the coccyx was reported to the physician. Review of the physician's orders/TAR failed to indicate a treatment for the coccyx area was ordered. Review of the Wound Evaluation and Management Summary, dated 12/5/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 3 x 1 centimeter (cm) x depth not measurable due to tissue overgrowth, open ulceration with light serous drainage (pale yellow/transparent drainage). Duration over three days. -Recommendation: Apply Silver sulfadiazine (antimicrobial cream to prevent infection) and calcium alginate (antibacterial product for wound drainage) twice daily, cover with gauze island border dressing. The new area identified on the 12/4/23 weekly skin check as shearing of the coccyx by the nurse, did not have a treatment in place at the time of the skin check, nor was one implemented when the area was discovered. The area was evaluated by the Wound Physician on 12/5/23 and determined to be MASD of the sacrum. Review of the TAR indicated the order was implemented on 12/6/23. Review of the Wound Evaluation and Management Summary, dated 12/19/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1 x 1 x 0.1 cm, open areas with exposed dermis (middle layer of skin). -Recommendation: Apply Collagen powder (wound filler to aid in formation of healthy tissue) daily, cover with gauze island border dressing twice daily. Review of the TAR failed to indicate the order was obtained for the new treatment as recommended. The order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 12/26/23, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1 x 0.5 x 0.1 cm, open areas with exposed dermis. -Recommendation: Apply Collagen powder daily, cover with gauze island border dressing twice daily. Review of the TAR indicated the order was implemented on 12/27/23 as follows: Sacrum-Cleanse with wound cleanser, pat dry, apply skin prep (forms a barrier between skin and adhesive to help preserve skin integrity) to surrounding skin, apply collagen powder to wound bed and cover with gauze island border dressing twice daily. (8 days after it was recommended) Further review of the December 2023 TAR indicated the treatments were not signed off as administered 7 out of 53 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/16/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1.5 x 0.5 x 0.1 cm, open areas with exposed dermis. Wound Progress: Not at goal. -Recommendation: Apply silver sulfadiazine and cover with gauze island border dressing twice daily. Review of the TAR indicated the order was implemented on 1/17/24 as follows: silver sulfadiazine apply to sacrum topically twice daily. No dressing was ordered as recommended to cover the wound. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of a dressing to cover the wound. The Resident was hospitalized from 1/18/24-1/26/24. Further review of the January 2024 TAR indicated the treatments were not signed off as administered 6 out of 45 opportunities. Review of the Wound Evaluation and Management Summary, dated 1/31/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) measured 1.5 x 0.4 x 0.1 cm, open areas with exposed dermis. Wound Progress: Not at goal. -Recommendation: Apply Collagen Sheet with silver (advanced dressing for management of wounds to reduce/prevent infection) and cover with gauze island border dressing twice daily. Review of the TAR failed to indicate an order was obtained for the collagen sheet with silver treatment as recommended. The order for silver sulfadiazine remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/8/24, indicated but was not limited to the following: - Site #9-Non-Pressure Wound Sacrum (MASD) was exacerbated and was now a Stage 3 Pressure Wound (full thickness tissue loss, subcutaneous fat may be visible but not bone, tendon, or muscle) and measured 1.5 x 2 x 0.1 cm with moderate serous drainage. -Recommendation: Apply Santyl (debriding agent to rid the wound of necrotic (dead) tissue and aid in healing) followed by calcium alginate and cover with gauze island border dressing daily. Review of the TAR failed to indicate an order was obtained for the Santyl and calcium alginate treatment as recommended. The order was written for Santyl Ointment-Apply to sacrum topically every day for wound care on 2/12/24. The order failed to contain the calcium alginate or a dressing to cover the wound. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 2/13/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 6 x 2 x 0.1 cm with moderate serous drainage. Wound Progress: Not at Goal. -Recommendation: Apply Calcium Alginate once daily and silver sulfadiazine twice daily cover with gauze island border dressing twice daily. The order was written as follows: Cleanse wound with wound cleanser, apply silver sulfadiazine to wound bed, apply calcium alginate then cover with gauze island border dressing twice daily. Review of the Wound Evaluation and Management Summary, dated 2/20/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Silver sulfadiazine twice daily cover with gauze island border dressing twice daily. -Skin substitute (alternative to a skin graft used to aid in healing of wounds not responding to typical treatment) wound candidate evaluation. Review of the TAR failed to indicate the silver sulfadiazine treatment as recommended. The previous order for silver sulfadiazine and calcium alginate remained in effect. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the February 2024 TAR indicated treatments were not signed off as administered 4 out of 57 opportunities. Review of the Wound Evaluation and Management Summary, dated 3/1/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: Silver sulfadiazine apply once weekly. If dressing falls off use silvadene and a border gauze daily. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The order from 2/13/24 was still in effect as it was not changed on 2/20/24 as recommended or on 3/1/24 as recommended. An order for silver sulfadiazine and cover with gauze island border twice daily was written on 3/4/24, also not per the recommendation made on 3/1/24 by the wound physician, the instructions pertaining to the skin substitute and full dressing were not included in the order. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 3/8/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1.5 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Xeroform gauze once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The previous incorrect order from 3/4/24 remained in effect until 3/11/24. On 3/11/24 orders were written as follows: -Maintain dressing to sacrum area, if dressing falls off apply the as needed (PRN) treatment of silver sulfadiazine with border gauze daily. -Cleanse area to sacrum wound with wound cleanser, apply silver sulfadiazine to wound followed by border gauze daily PRN if dressing falls off. The incorrect order from 3/4/24 remained in effect until 3/11/24, therefore the newly applied skin substitute graft from 3/8/24 was disturbed that evening and the wrong treatment continued until 3/11/24, when an order was written to maintain the sacrum dressing (which had already been disturbed) and therefore should have had daily dressing changes until the next wound physician visit and it did not. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 3/19/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 4 x 1 x 0.1 cm with light serous drainage. Wound Progress: Not at goal. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Collagen sheet with silver apply once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. On 3/20/24 orders were written as follows: -Maintain dressing to sacrum area, if dressing falls off apply the PRN treatment of collagen sheet with silver followed by border gauze daily. Every shift for sacrum dressing. -Maintain restorigin/border gauze dressing to sacrum until wound MD in to re-evaluate, check placement every shift. If soilage is noted to the border gauze, change the border gauze as needed (see PRN order) if entire dressing falls off, refer to PRN collagen sheet with silver every shift for sacrum wound. The TAR failed to indicate an order for if dressing falls of use silvadene and border gauze daily. The order was written for a collagen sheet with silver followed by a border gauze daily. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the March 2024 TAR indicated treatments were not signed off as administered 6 out of 21 opportunities. Review of the Wound Evaluation and Management Summary, dated 4/9/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: If dressing falls off use silvadene and a border gauze daily. Collagen sheet with silver apply once weekly. For the week of 4/15 apply Collagen AG and a border gauze once daily. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The incorrect orders written 3/20/24 remained in effect. The additional order for the week of 4/15/24 as indicated above was not written until 4/17/24 and initiated on 4/18/24. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Collagen sheet with silver apply once weekly. Calcium Alginate once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Secondary Dressing: Gauze Island border once weekly. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The order was written for daily dressing changes as follows: Cleanse area to sacrum wound with wound cleanser, pat dry, apply skin prep to surrounding skin, apply collagen AG sheet with silver and calcium alginate sheet to wound followed by a border gauze dressing every day shift for wound care. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated but was not limited to the following: - Site #9-Stage 3 Pressure Wound and measured 1.2 x 1 x 0.1 cm with light serous drainage. -Recommendation: Primary Dressing: Collagen sheet with silver apply once weekly. Hydrocolloid sheet (satin) (moisture-retentive dressing with gel properties and waterproof to isolate wound from bacteria contaminants) once weekly. Skin substitute application (Restorigin) apply once weekly. DO NOT REMOVE or disturb the wound bed. Change the secondary dressing with care per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the next visit. Review of the TAR failed to indicate an order was obtained for the treatment as recommended. The orders written included the gauze island border dressing and not the hydrocolloid sheet. The order written 5/1/24 read as follows: -Maintain the Restorigin/Border gauze dressing to sacrum wound until Wound MD in to re-evaluate, check placement every shift. If soilage is noted to the border gauze change the border gauze as needed (see PRN order). If entire dressing falls off, refer to PRN Collagen sheet with silver every shift for sacrum wound. Review of the TAR indicated the wound descriptors including the drainage amount/type and wound bed. These descriptors were documented on daily basis, indicated the wound bed was exposed and assessed daily. Additionally, the PRN order to change the dressing for soilage and the PRN order if the entire dressing falls off were not signed off as administered. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Further review of the April 2024 TAR indicated treatments were not signed off as administered 3 out of 13 opportunities. Review of the Wound Evaluation and Management Summary, dated 5/7/24, indicated but was not limited to the following: -[TRUNCATED]

Based on record review, interview, observation, and policy review, the facility failed to provide services that met professional standards of quality for four Residents (#4, #117, #2, and #110), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #4 to accurately transcribe and implement orders for changes in pressure and non-pressure wound treatments (Wound Site #8, #9, #10, #11 ,#12, #13, #14, #15, and #16), resulting in Wound Site #9 progressing from a non-pressure wound to a Stage 3 pressure ulcer; 2. For Resident #117, to accurately transcribe and implement orders for changes in pressure wound treatments; 3. For Resident #2, to accurately transcribe and implement orders for changes in pressure wound treatments; and 4. For Resident #110, to accurately transcribe and implement orders for changes in pressure wound treatments. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. - In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Charting and Documentation, dated as revised 10/2019, included but was not limited to the following: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, should be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. -The following information is to be documented in the resident medical record: Treatments or services performed. -Documentation of procedures and treatments will include care-specific details Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: -If a new skin alteration is noted, initiate a pressure/non pressure form related to the type of alteration noted. -The following information should be recorded in the resident's medical record utilizing facility forms: the condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified; documentation in the medical record addressing Physician notification if new skin alteration noted with change of plan of care, if indicated. 1. Resident #4 was admitted to the facility in January 2010, and recently readmitted in January 2024 with diagnoses including morbid obesity, diabetes mellitus with diabetic polyneuropathy (symptoms of numbness, weakness, and decreased sensation usually starting in feet/hands), and peripheral vascular disease (PVD-narrowing of blood vessels causing decreased blood flow). Review of the Minimum Data Set (MDS) assessment, dated 3/27/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #4 had skin treatments and was dependent on staff for assistance with positioning. Review of the comprehensive care plan indicated but was not limited to the following: FOCUS: Pressure Ulcer: Ulceration or interference with structural integrity of layers of skin. GOAL: Show no signs of infection through review date; Show reduction in size/stage of pressure ulcer. INTERVENTIONS: Consult and treatment by Certified Wound Doctor or Certified Wound Nurse as needed (PRN), monitor for changes and update provider, offload heels as tolerated when in bed, offload wounds as tolerated, treatments as ordered, and turn/reposition as needed. Review of the medical record indicated Resident #4 was followed by a Wound Care Physician at the facility. a. Site #8-Stage 2 Pressure Wound of the Right Buttock. (Partial thickness loss of dermis (middle layer of skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow/white material in wound bed) or bruising) Review of the initial Wound Evaluation and Management Summary, dated 12/5/23 indicated the following: -Site #8-Stage 2 Pressure Wound of the Right Buttock measured 3 x 2 cm x depth is unmeasurable due to presence of tissue overgrowth. Review of the Wound Evaluation and Management Summaries (18 visits) indicated the following: -Start of Care for Site #8 was 12/5/23 and the area resolved on 4/30/24. -Of the weekly wound care recommendations made 5 of 11 were transcribed accurately as recommended, 6 of 11 were not transcribed accurately and 6 visits no change was needed; the visit on 4/30/24 the area was resolved. Review of the Treatment Administration Record (TAR) from 12/5/23-4/30/24 indicated the facility failed to complete the treatment ordered on the TAR 30 of 266 opportunities. b. Site #9-Non-Pressure Wound Sacrum (area at the lower spine) (Moisture Associated Skin Damage (MASD)-caused by prolonged exposure to various sources of moisture including urine or stool, perspiration, wound exudate (drainage), mucus, saliva, and their contents). Review of the initial Wound Evaluation and Management Summary, dated 12/5/23 indicated the following: - Site #9-Non-Pressure Wound Sacrum measured 2 x 1 x 0.1 cm. Review of the Wound Evaluation and Management Summaries (20 visits) indicated the following: -Start of Care for Site #9 was 12/5/23 and the area is still currently under the care of the Wound Physician for the Pressure Wound. -The wound was reclassified due to exacerbation from MASD to a Stage 3 Pressure Ulcer (Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss) on 2/8/24. -Of the weekly wound care recommendations made 5 of 18 were transcribed accurately as recommended, 13 of 18 were not transcribed accurately and 2 visits no change was needed. Review of the TAR from 12/5/23-5/22/24 indicated the facility failed to complete the treatment ordered on the TAR 4 of 66 opportunities. c. Site #10-Unstageable Wound of the Right Lateral Foot. (Full thickness pressure injury in which the base is obscured by slough and/or eschar (dead tissue that dries and becomes adherent to the wound)) Review of the initial Wound Evaluation and Management Summary, dated 12/5/23, indicated the following: -Site #10-Unstageable Wound of the Right Lateral Foot measured 2.5 x 1.5 cm x depth not measurable due to presence of non-viable tissue and necrosis. Review of the Wound Evaluation and Management Summary, dated 1/16/24, indicated but was not limited to the following: - Site #10-Stage 3 Pressure Wound of the Right Lateral Foot measured 3.5 x 2.5 x 0.1 cm with moderate serous drainage. Wound Progress: Not at Goal. -Recommendation: Apply calcium alginate and silver sulfadiazine and cover with gauze island border dressing twice daily. Off-load wound, float heels in bed. The surface area of the wound was four times larger than the previous visit and the wound now had 20% thick adherent devitalized necrotic tissue (not present on previous visit (1/2/24)). Review of the nursing progress notes failed to indicate staff had identified the decline in the wound and notified the Physician since the previous visit (1/2/24). Review of the TAR failed to indicate the order was obtained for the new treatment as recommended by the wound physician. The order written for Silver Sulfadiazine failed to include the calcium alginate or a dressing. Review of the nursing and physician progress notes failed to indicate the Physician declined the recommendation of the Wound Physician. Review of the nursing progress notes indicated Resident #4 had been diagnosed with influenza on 1/16/24 and treatment was initiated. He/she spiked a temp on 1/18/24 and was transferred to an acute care hospital. The Resident was hospitalized from 1/18/24-1/26/24. Review of the History and Physical, dated 1/18/24, indicated: -Treatment for Sepsis (life-threatening complication of an infection) without septic shock is likely secondary to urinary tract infection (UTI) and right foot ulcer. Review of the Hospital Discharge Summary, dated 1/26/24, indicated: -Infectious Disease Consult 1/18/24-reason Sepsis. -Podiatry Consult 1/18/24-reason right lateral foot ulcer, ?osteomyelitis. -Sepsis secondary to right foot ulcer. Could not do the MRI. Per Infectious Disease (ID) will do two weeks of intravenous (IV) Ceftriaxone (antibiotic). -Discharge Data: Sepsis with acute organ dysfunction. -Discharge Diagnosis: Right foot infection. -Discharge Information: Skin Comment: Pressure Injury Right Lateral Foot: Cleanse with normal saline or wound cleanser, apply protective skin barrier spray/wipe or skin barrier cream, protect with foam dressing, change every other day, or as needed. Review of the nursing progress note, dated 1/26/24, indicated the change in treatment per hospital orders and IV antibiotics for right foot sepsis. Review of the TAR failed to indicate the wound care order was obtained per the discharge instructions from the hospital. The Silver Sulfadiazine treatment remained in effect since ordered on 1/17/24, still without the calcium alginate or a dressing. Review of the nursing progress notes failed to indicate the Physician declined the recommendation from the hospital discharge instructions. Review of the Wound Evaluation and Management Summaries (18 visits) indicated the following: -Start of Care for Site #10 was 12/5/23 and the area resolved on 4/30/24, and exacerbated on 5/23/24, pending evaluation on 5/24/24. -Of the weekly wound care recommendations made 6 of 11 were transcribed accurately as recommended, 5 of 11 were not transcribed accurately and 6 visits no change was needed; the final on 4/30/24 the area was resolved. Review of the TAR from 12/5/23-4/30/24 indicated the facility failed to complete the treatment ordered on the TAR 40 of 234 opportunities. d. Site #11-Non-Pressure Wound of the Right Thigh (trauma/from brief) Review of the initial Wound Evaluation and Management Summary, dated 12/19/23, indicated the following: -Site #11-Non-Pressure Wound of the Right Thigh measured 2.5 x 2.5 cm x depth not measurable due to presence of tissue overgrowth. Review of the Wound Evaluation and Management Summaries (5 visits) indicated the following: -Start of Care for Site #11 was 12/19/23 and the area resolved on 1/31/24. -Of the weekly wound care recommendations made 1 of 4 were transcribed accurately as recommended, 3 of 4 were not transcribed accurately; the visit on 1/31/24 the area was resolved. Review of the TAR from 12/19/23-1/31/24 indicated the facility failed to complete the treatment ordered on the TAR 3 of 14 opportunities. e. Site #12-Stage 3 Pressure Wound of the Left Buttock. Review of the initial Wound Evaluation and Management Summary, dated 1/31/24, indicated the following: -Site #12-Stage 3 Pressure Wound of the Left Buttock measured 4.5 x 1 x 0.1 cm. Review of the Wound Evaluation and Management Summaries (3 visits) indicated the following: -Start of Care for Site #12 was 1/31/24 and the area resolved on 2/13/24. -Of the weekly wound care recommendations made 0 of 2 were transcribed accurately as recommended, 2 of 2 were not transcribed accurately; the visit on 2/13/24 the area was resolved. Review of the TAR from 1/31/23-2/13/24 indicated the facility failed to complete the treatment ordered on the TAR 3 of 14 opportunities. f. Site #13-Skin Tear of the Right Shin. Review of the initial Wound Evaluation and Management Summary, dated 1/31/24 indicated the following: -Site #13-Skin Tear of the Right Shin measured 2 x 3 cm x depth unmeasurable due to presence of tissue overgrowth. Review of the Wound Evaluation and Management Summaries (2 visits) indicated the following: -Start of Care for Site #13 was 1/31/24 and the area resolved on 2/8/24. -Of the weekly wound care recommendations made 0 of 1 were transcribed accurately as recommended, 1 of 1 were not transcribed accurately; the visit on 2/8/24 the area was resolved. Review of the TAR from 1/31/23-2/8/24 indicated the facility failed to obtain an order for a treatment. g. Site #14-Stage 3 Pressure Wound of the Left Buttock. Review of the initial Wound Evaluation and Management Summary, dated 2/20/24, indicated the following: -Site #14-Stage 3 Pressure Wound of the Left Buttock measured 1.5 x 1 cm x depth unmeasurable due to presence of tissue overgrowth. Review of the Wound Evaluation and Management Summaries (5 visits) indicated the following: -Start of Care for Site #14 was 2/20/24 and the area resolved on 3/19/24. -Of the weekly wound care recommendations made 1 of 2 were transcribed accurately as recommended, 1 of 2 were not transcribed accurately and 2 visits no change was needed; the visit on 3/19/24 the area was resolved. Review of the medical record indicated that from 2/20/24-3/4/24 the facility failed to obtain an order for a treatment to the left buttock. Review of the physician's orders indicated that on 3/4/24 an order was obtained for the left buttock. (14days after the onset of the wound) Review of the TAR from 3/4/24-3/19/24 indicated the facility failed to complete the treatment ordered on the TAR 6 of 32 opportunities. Review of the Pressure Ulcer Evaluations, dated 2/21/24, failed to indicate a pressure area to the left buttock. h. Site #15-Non-Pressure Wound of the Right Buttock (MASD). Review of the medical record indicated a previous area to the right buttock had resolved on 5/1/24. Review of the initial Wound Evaluation and Management Summary, dated 5/14/24, indicated the following: -Site #15-Non-Pressure Wound of the Right Buttock (MASD) measured 3 x 2 cm x depth unmeasurable due to presence of tissue overgrowth. Review of the Wound Evaluation and Management Summaries (1 visits) indicated the following: -Start of Care for Site #15 was 5/14/24 and the area is still currently under the care of the Wound Physician. Review of the TAR from 5/14/23-5/22/24 indicated the facility failed to complete the treatment ordered on the TAR 1 of 7 opportunities. i. Site #16-Non-Pressure Wound of the Right Thigh (trauma/from brief). Review of the initial Wound Evaluation and Management Summary, dated 5/14/24, indicated the following: -Site #16-Non-Pressure Wound of the Right Thigh (trauma/from brief) measured 4.5 x 0.5 x 0.1 cm. Review of the Wound Evaluation and Management Summaries (1 visits) indicated the following: -Start of Care for Site #16 was 5/14/24 and the area is still currently under the care of the Wound Physician. Review of the TAR from 5/14/23-5/22/24 indicated the facility failed to complete the treatment ordered on the TAR 1 of 6 opportunities. During an interview on 5/21/24 at 4:06 P.M., Unit Manager #1 said the Wound Doctor comes weekly and usually rounds with Nurse #5, then she would get the recommendations from the Wound Doctor and write/obtain all the orders. She said the non-pressure and pressure ulcer evaluations trigger to be done weekly once initiated and every area should have one done weekly. During a telephone interview on 5/23/24 at 8:51 A.M., Nurse #5 said she does the weekly wound rounds with the Wound Doctor and writes the orders. She said typically the Attending Physician or NP goes with whatever the Wound Doctor recommends unless it is something out in left field but that rarely happens. Nurse #5 was not in the building during the interview and did not have access to the medical records at the time of the interview. She said she couldn't speak to the recommendations that were not done prior to her taking over in late April but said if her name is on the current orders then she wrote them. She was unable to speak to why the orders from May were not written and/or did not match the Wound Doctor Recommendations as they should because the physician did not disagree with the recommendations. During an interview on 5/23/24 at 9:26 A.M., the DON said the general process is the Nurse rounds with the Wound Doctor, then obtains orders and write them per the Wound Doctor Recommendations and completes the weekly pressure/non-pressure evaluations. She said there is no process in place at this time to ensure orders are transcribed correctly and treatments are implemented but there needs to be one. Additionally, she said she expects treatments to be done per the physician's order and signed off on the TAR and there should not be blanks (treatment not signed off as administered) on the TAR. The DON and Consulting Staff #1 confirmed with chart review multiple treatments as noted above were not implemented correctly or at all and they should have been. Given the number of errors noted, not every treatment was reviewed by the DON and Consulting Staff #1 for accuracy. She said the number of things not done correctly was concerning. Additionally, the DON said the orders should match the recommendation unless the Attending disagreed and in that case there should be a progress note written and there are no notes indicating such. She also said if the recommendation is unclear, or a secondary dressing was not written on the recommendation, then the nurse should be calling the Wound Doctor for clarification. During an interview on 5/23/24 at 9:26 A.M., the DON and Consulting Staff #1 confirmed with chart review that multiple treatments as noted above were not implemented correctly or at all and they should have been. Given the number of errors noted, not every treatment was reviewed by the DON and Consulting Staff #1 for accuracy. During an interview on 5/23/24 at 12:40 P.M., Unit Manager #1 said she expects treatments to be done per the physician's order and signed off on the TAR. During an interview on 5/23/24 at 3:30 P.M., the Wound Doctor said her expectation is for the Nurse to obtain and write the orders per the recommendations made and if they need clarification to call her. She said the Attending Physicians/NP's always go with whatever is recommended and she has never had any issues with them disagreeing with what she recommended. Refer to F684 and F686 36542 2. Resident #117 was admitted to facility in April 2024 with a pressure ulcer to the coccyx (bone at the end of the spine). Review of the Minimum Data Set (MDS) assessment, dated 4/30/24, indicated Resident #117 was dependent on staff for all activities of daily living (ADLs) and mobility. Review of the care plans indicated Resident #117 had a stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) pressure ulcer to the coccyx with interventions of administering treatments as ordered, utilize an air mattress, and to follow facility protocol for the prevention/treatment of skin breakdown. Review of the admissions paperwork indicated Resident #117 was admitted with a pressure wound to the coccyx with a treatment order to cleanse with normal saline, pat dry, apply wound gel with silver, followed by Calcium Alginate with silver, apply skin prep to peri-wound (the skin around the wound) and cover with a super absorbent dressing, two times per day and as needed. Review of the Treatment Administration Record (TAR) for April 2024 indicated the treatment from admission was not completed as ordered on the following days: -4/19/24 (day and evening shift) -4/21/24 (day shift) -4/22/24 (day shift) Review of the Wound Evaluation and Management Summary from the Consultant Wound Physician, dated 4/23/24, indicated the following: Stage 3 pressure ulcer of the left coccyx: measuring 3 centimeters (cm) in length by 1 cm in width by 0.1 cm in depth, with light serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) drainage with 100% granulated tissue. Treatment Plan: Discontinue wound gel with silver, Calcium Alginate with silver and super absorbent dressing. Start Silver Sulfadiazine (an antibiotic cream used to treat or prevent serious skin infections) twice per day with a gauze island border dressing. During an interview on 5/22/24 at 3:17 P.M., Nurse Practitioner #2 said the primary physicians defer to the Wound Physician for treatments and she had not declined any recommendations for Resident #117. Review of the TAR for April 2024 indicated no treatment was provided to the stage 3 pressure ulcer on 4/24/24. Review of the April 2024 TAR indicated a new treatment order was written on 4/24/24 to start on 4/25/24: cleanse the coccyx with normal saline, apply Silver Sulfadiazine cream to area and cover with gauze island border dressing once per day, and not twice per day as indicated by the Wound Physician. The treatment was provided once per day from 4/25/24 through 4/29/24. Review of the Wound Evaluation and Management Summary from the Consultant Wound Physician, dated 4/30/24, indicated the following: Stage 3 pressure ulcer of the left coccyx: measuring 2.5 cm in length by 1 cm in width by 0.1 cm in depth, with light serous drainage with 80% granulated tissue and 20% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). Treatment Plan: Continue Silver Sulfadiazine twice per day with a gauze island border dressing. Review of the TAR for May 2024 indicated no treatment was provided to the stage 3 pressure ulcer on 5/1/24. Review of the May 2024 TAR indicated the treatment order for the coccyx pressure ulcer was re-written on 5/1/24 to include documentation requirements including wound descriptions. The treatment order continued to be in place for once per day and not twice per day as indicated by the Wound Physician. Review of the Wound Evaluation and Management Summary from the Consultant Wound Physician, dated 5/7/24 indicated the following: Stage 3 pressure ulcer of the left coccyx: measuring 3 cm in length by 1 cm in width by 0.2 cm in depth, with moderate serous drainage with 80% granulated tissue and 20% slough. Treatment Plan: Discontinue Silver Sulfadiazine twice per day; Start Alginate Calcium with silver and Collagen Powder, once per day, followed by the gauze island border dressing. Review of the TAR for May 2024 indicated no treatment was provided to the stage 3 pressure ulcer on 5/8/24. Review of the May 2024 TAR indicated the new treatment order for the coccyx pressure ulcer was written on 5/8/24 as indicated by the Wound Physician. The TAR indicated this treatment was not provided on 5/11/24 and 5/12/24. Review of the Wound Evaluation and Management Summary from the Consultant Wound Physician, dated 5/14/24, indicated the following: Stage 3 pressure ulcer of the left coccyx: measuring 2.3 cm in length by 1 cm in width by 0.2 cm in depth, with moderate serous drainage with 80% granulated tissue and 20% slough. Treatment Plan: Continue Alginate Calcium with silver and Collagen Powder, once per day, followed by the gauze island border dressing. Review of the TAR for May 2024 indicated no treatment was provided to the stage 3 pressure ulcer on 5/15/24. Review of the May 2024 TAR indicated the treatment order for the coccyx pressure ulcer was re-written on 5/15/24 to start on 5/16/24 as follows: normal saline, apply Collagen Powder followed by Calcium Alginate and cover with gauze island border dressing; indicating the treatment no longer included silver in the Calcium Alginate. The treatment was not provided on 5/18/24 or 5/20/24. During an interview on 5/22/24 at 12:15 P.M., Nurse #3 said she always completes the treatments for Resident #117 and could not say why the treatments were not completed on days she was working, such as 5/11/24 and 5/15/24. She said if a treatment order was discontinued prior to her completing the order and the next treatment order did not start until the following day there was no way for her to be alerted by the electronic medical record that a treatment needed to be completed. During an interview on 5/23/24 at 8:51 A.M., Nurse #5 said she was not sure why the treatments were not completed as ordered by the nurses and that she does not check the TAR to ensure wound treatments are completed as ordered and would not know if treatments are not being completed. She said all treatment orders should have been written to reflect the treatment plan indicated by the Wound Physician and she was not sure why they were not. Refer to F686 49425 3. Resident #2 was admitted to the facility in April 2019 with diagnoses of Type 2 Diabetes and a stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) to the coccyx (area below the spine). Review of the MDS assessment, dated 5/1/24, indicated Resident #2 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #2 cognition was severely impaired. Review of Section M: Skin Conditions of the MDS assessment indicated the Resident had a Stage 4 pressure ulcer/injury. The assessment also indicated Resident #2 was receiving pressure ulcer/injury care including the application of non-surgical dressings and ointments. Review of the care plans for Resident #2 indicated the Resident had a Stage 4 pressure ulcer to the coccyx with interventions to consult certified wound MD or Nurse as needed and monitor for changes and update provider. Review of the April 2024 Medication and Treatment Administration Records (MAR and TAR) indicated the following treatment order for the coccyx was initiated on 4/25/24: Cleanse area to coccyx with wound cleanser, apply Santyl (debriding ointment used to rid wound bed of dead tissue), Collagen Sheet (stimulates growth of new tissue), and Calcium Alginate (absorbent gel forming debriding agent to rid wound bed of dead tissue). Cover with gauze island border dressing, change daily and as needed soilage on day shift. Review of the medical record indicated Resident #2 was seen by the Wound Physician Consultant on 4/30/24. Review of the Wound Evaluation Management Summary indicated Resident #2 had a Stage 4 pressure injury to the coccyx measuring 6 centimeters (cm) in length by 6 cm in width by 1.5 cm in depth. The treatment recommendation was to change the treatment to apply Collagen Sheet, Alginate Calcium with Silver, and cover with gauze island border dressing daily for 23 days. Review of the Nursing Progress Note, dated 5/1/24, indicated Resident #2 was seen by the Wound Physician with wound measurements and treatments updated. MD and guardian aware of changes and in agreement with plan of care. Review of the Pressure Ulcer Evaluation, dated 5/1/24, indicated there was a new order for the pressure injury to the coccyx to apply Collagen Sheet, followed by Alginate Calcium with Silver, cover with a gauze island with border dressing and change daily. Review of the May 2024 MAR and TAR indicated a new treatment order was initiated on 5/1/24 for the coccyx area: -Cleanse area to coccyx with wound cleanser, apply Collagen Sheet followed by Calcium Alginate. Cover with gauze island border dressing. Change daily and as needed for soilage. Review of the May 2024 MAR and TAR failed to indicate Alginate Calcium with Silver was initiated. Review of the 5/7/24 Wound Evaluation and Management Summary from the Wound Physician indicated to continue the Collagen sheet, followed by Alginate Calcium with Silver, cover with gauze island border dressing daily for 16 days. Review of the Nursing Progress Notes, dated 5/8/24, indicated Resident #2 was seen by the Wound Physician with measurements and treatments updated. MD and guardian aware of plan of care and agree. Review of the Pressure Ulcer Evaluation, dated 5/8/24, indicated to continue current treatment order of Collagen Sheet, followed by Alginate Calcium with Silver, cover with gauze island border dressing daily. Review of the 5/14/24 Wound Evaluation and Management Summary from the Wound Physician indicated to continue the Collagen sheet, followed by Alginate Calcium with Silver, cover with gauze island border dressing daily for 9 days. Review of the Nursing Progress Notes, dated 5/15/24, indicated Resident #2 was seen by the wound physician with measurements and treatments updated. MD and guardian aware of plan of care and agree. Review of the Pressure Ulcer Evaluation, dated 5/15/24, indicated to continue current treatment order of collagen sheet, followed by Alginate Calcium with Silver, cover with gauze island border dressing daily. Review of the May 2024 MAR and TAR failed to indicate the treatment of Alginate Calcium with Silver was implemented between 5/1/24 and 5/21/22. Review of the Nursing Progress Notes, dated 5/21/24, indicated Resident #2 wound orders were updated by Nurse Practitioner related to Alginate Calcium being unavailable at this time, use Alginate Calcium with Silver, until Alginate Calcium is available, guardian in agreement. Review of the May 2024 MAR and TAR indicated a new order: -Cleanse area to coccyx with wound cleanser, apply Collagen Sheet followed by Calcium Alginate with Silver, cover with gauze island border dressing. Change daily and as needed for soilage. Review of the May 2024 MAR and TAR failed to indicate a treatment was completed on 5/21/24 to the coccyx. The TAR was blank. Review of the Nursing progress notes, dated 5/21/24, failed to indicate a treatment was completed to the coccyx. During an interview on 5/21/24 at 1:42 P.M., Unit Manager (UM) #3 said the facility ran out of Alginate Calcium and they notified the Nurse Practitioner (NP), and the order was updated to include Alginate Calcium with Silver. The surveyor and UM reviewed wound physician's recommendations together and she said the order was in the system incorrectly, and it should have always included Alginate Calcium with Silver since 5/1/24. During an interview on 5/22/24 at 2:31 P.M., Nurse #9 said the standard of practice would be to document completion of the treatment on the TAR. She said she will also document in a nursing progress note if she has more information to add regarding the treatment she provided. Nurse #9 said she must have forgotten to document after completing the treatment to Resident #2 coccyx area. During an interview on 5/22/24 at 3:17 P.M., Nurse Practitioner #2 said she defers to the wound physician for wound recommendations. She said she has not declined any wound recommendations for Resident #2. During an interview on 5/22/24 at 4:22 P.M., UM #3 said the process for a nurse to follow once completing a treatment would be to sign off on the TAR. The surveyor and UM #3 reviewed the TAR and Nursing Progress Notes together and she said the nurse did not document completion of the treatment in the medical record on 5/21/24. During an interview on 5/23/24 at 9:05 A.M., Nurse #5 said she regularly conducted wound rounds with the wound physician. She said the wound physician would give her verbal recommendations and send over the Wound Evaluation and Management Summary with the written recommendations, and she reviewed them with the PCP. Nurse #5 said the PCP did no [TRUNCATED]

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required the physical assistance of two staff members with bed mobility and was assessed by nursing as being at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1 who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid. Findings include: Review of the Facility's Policy, titled Care Plans, dated as revised January 2024, indicated the following: -a comprehensive, person-centered care plan will be developed for each resident; -the care plan will include objectives that meet the resident's physical, psychosocial and functional needs; -the Interdisciplinary Team (IDT) in conjunction with the resident and his/her family may assist with the development of a comprehensive care plan; -care plan interventions are derived from information gathered as part of the comprehensive assessment; -evaluation of residents is ongoing and care plans are revised as information about the resident and the resident conditions change; -the IDT team reviews and updated the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly MDS assessment; Resident #1 was admitted to the Facility in September 2022, diagnoses included cerebral infarction due to embolism, degenerative disease of the nervous system, joint disorder, tremor, anxiety, major depressive disorder, dementia with behavioral disturbance and alcohol abuse. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was totally dependent on staff with rolling from side to side in bed. Review of Resident #1's Care Plan related to Activities of Daily Living, renewed and reviewed with his/her December 2023 MDS, indicated that he/she was dependent on the physical assistance of two staff members with bed mobility. Review of Resident #1's current Resident Care Card, (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility, which included turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 02/02/24, indicated that on 01/28/24 at 6:15 A.M., a CNA was providing care to Resident #1, turned to rinse out the wash cloth, and Resident #1 rolled out of bed on the opposite side of the bed from where the CNA was standing, landed on the floor and sustained a laceration to his/her lower eyelid. The Report further indicated that the CNA was aware that Resident #1 required the physical assistance of two staff members with turning and repositioning. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation of his/her injury and returned with sutures to his lower eyelid. Review of a Nurse Progress Note, dated 01/28/24 at 6:47 A.M., (written by Nurse #1) indicated that a CNA (later identified as CNA #1) called her into Resident #1's room and he/she (Resident #1) was found on the floor on his/her face. The Note indicated that the CNA was changing Resident #1 in bed, stepped out of the room, and upon return found Resident #1 on the floor with blood coming from his/her face and head. The Note indicated that upon assessment, Resident #1 presented with an egg-shaped area on his/her forehead and blood coming from the bridge of nose and right eye socket. The Note indicated that Resident #1 was sent out 911 (Emergency Medical Services) for evaluation of his/her injuries. During a telephone interview on 03/04/24 at 4:48 P.M., (which included review of her written witness statement), Nurse #1 said that Resident #1 required the physical assistance of two staff members with bed mobility, that he/she was restless in bed, combative with care and was at high risk for falls. Nurse #1 said that on 1/28/24 at 6:15 A.M., she was passing out medications when a CNA (later identified as CNA #1) yelled out for a nurse. Nurse #1 said that when she entered Resident #1's room he/she was face down on the floor with blood coming from his/her eye area and there was a lot of blood on the floor. Nurse #1 said that CNA #1 stayed with Resident #1 while she called 911. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 1/28/24, indicated that she washed Resident #1's face and turned her back to soak the washcloth again, and in a fraction of a second, he/she rolled out of bed and fell on his/her face. The Statement indicated that Resident #1 hit under his/her eye and was bleeding. During a telephone interview on 2/28/24 at 10:12 A.M., CNA #1 said that when she provided care to Resident #1 on the morning of 1/28/24, that she knew that Resident #1 was a fall risk and required the physical assistance of two staff members with bed mobility and turning and repositioning in bed. CNA #1 said that she has taken care of Resident #1 many times prior to the incident. CNA #1 said that she thought she could provide care to Resident #1 in bed by herself and said she did not follow Resident #1's plan of care. Review of a Hospital Emergency Department Discharge Summary, dated 01/28/24, indicated that Resident #1 was in his/her room with a caregiver when she turned her back and Resident #1 fell on his/her face on the floor. The Summary indicated that Resident #1 sustained a closed head injury and a 2 centimeter (cm) right lower eyelid laceration which required five absorbable sutures to close the wound. During an interview on 02/27/24 at 2:30 P.M., the Director of Nurses (DON) said that Resident #1 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #1 provided care to Resident #1 in bed without the assistance of another staff member and said Resident #1 fell out of bed on the opposite side of the bed from where CNA #1 was standing. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff follow the plan of care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required the physical assistance of two staff members with bed mobility, the Facility failed he/she was provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed, on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid. Findings include: Review of the Facility's Policy, titled Assessing Falls and Their Causes, dated as revised January 2018, indicated the following: -review the resident's care plan to assess for any special needs of the resident; -after an observed fall, staff will clarify the details of the fall; -staff will evaluate the chain of events preceding a recent fall; -staff will continue to collect and evaluate the information until they identify the cause of the fall; -staff will complete a falls risk assessment; -staff will document appropriate interventions taken to prevent future falls. Review of the Facility's Policy, titled Safety and Supervision of Residents, dated April 2028, indicated the following: -the facility strives to make the environment as free from accident hazards as possible; -safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes; -employees shall be trained on potential accident hazards and report accident hazards and try to prevent avoidable accidents; -care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; -implementation of interventions and monitoring the effectiveness of interventions; -resident supervision is a core component of the systems approach to safety; Resident #1 was admitted to the Facility in September 2022, diagnoses included cerebral infarction due to embolism, degenerative disease of the nervous system, joint disorder, tremor, anxiety, major depressive disorder, dementia with behavioral disturbance and alcohol abuse. Review of Resident #1's Fall Risk Evaluation, dated 12/01/23, indicated that he/she was at high risk for falls. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was totally dependent on staff with rolling from side to side in bed. Review of Resident #1's Care Plan related to Activities of Daily Living, renewed and reviewed with his/her December 2023 MDS, indicated that he/she was dependent on the physical assistance of two staff members with bed mobility. Review of Resident #1's Current Resident Care Card, (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility and with turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 02/02/24, indicated that on 01/28/24 at 6:15 A.M., a CNA (later identified as CNA #1) was providing care to Resident #1, turned to rinse out the wash cloth, and Resident #1 rolled out of bed on the opposite side of the bed from where the CNA was standing, landed on the floor and sustained a laceration to his/her lower eyelid. The Report further indicated that the CNA was aware that Resident #1 required the physical assistance of two staff members with turning and repositioning. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation of his/her injury and returned with sutures to his lower eyelid. Review of a Nurse Progress Note, dated 01/28/24 at 6:47 A.M., (written by Nurse #1) indicated that a CNA (later identified as CNA #1) called her into Resident #1's room and he/she (Resident #1) was found on the floor on his/her face. The Note indicated that the CNA was changing Resident #1 in bed, stepped out of the room, and upon return found Resident #1 on the floor with blood coming from his/her face and head. The Note indicated that upon assessment, Resident #1 presented with an egg-shaped area on his/her forehead and blood coming from the bridge of nose and right eye socket. The Note indicated that Resident #1 was sent out 911 (Emergency Medical Services) for evaluation of his/her injuries. During a telephone interview on 03/04/24 at 4:48 P.M., (which included review of her written witness statement), Nurse #1 said that on 1/28/24 at 6:15 A.M., she was passing out medications when a CNA (later identified as CNA #1) yelled out for a nurse. Nurse #1 said that when she entered Resident #1's room he/she was face down on the floor with blood coming from his/her eye area and there was a lot of blood on the floor. Nurse #1 said that CNA #1 stayed with Resident #1 while she called 911. Nurse #1 said that Resident #1 required the physical assistance of two staff members with bed mobility, he/she was restless in bed, combative with care and was at high risk for falls. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 1/28/24, indicated that she washed Resident #1's face, turned her back to soak the washcloth again, and in a fraction of a second, he/she rolled out of bed and fell on his/her face. The Statement indicated that Resident #1 hit under his/her eye and was bleeding. During a telephone interview on 2/28/24 at 10:12 A.M., CNA #1 said that on the morning of 1/28/24, she washed Resident #1's face, she turned her back to soak the facecloth, he/she (Resident #1) made a quick turn, fell out of bed, and landed on a bedside table on his/her face in a matter of seconds. CNA #1 said that she tried to grab him/her, but she was unable to reach him/her because Resident #1 fell out of bed on the opposite side of where she was standing. CNA #1 said that she knew that Resident #1 was a fall risk and required the physical assistance of two staff members with bed mobility and turning and repositioning in bed. CNA #1 said that she has taken care of Resident #1 many times prior to the incident. CNA #1 said that she thought she could provide care to Resident #1 in bed by herself, and had not gotten another staff member to assist her. Review of a Hospital Emergency Department Discharge Summary, dated 01/28/24, indicated that Resident #1 was in his/her room with a caregiver when she turned her back and Resident #1 fell on his/her face on the floor. The Summary indicated that Resident #1 sustained a closed head injury and a 2 centimeter (cm) right lower eyelid laceration which required five absorbable sutures to close the wound. During an interview on 02/27/24 at 2:30 P.M., the Director of Nurses (DON) said that Resident #1 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #1 provided care to Resident #1 in bed without the assistance of another staff member and said Resident #1 fell out of bed on the opposite side of the bed from where CNA #1 was standing. The DON said Resident #1 was not provided with the necessary level of staff assistance for safety during care.

Based on record review, policy review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#55 and #95), out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #55, follow their policy and ensure an allegation of a resident-to-resident altercation was thoroughly investigated, protective interventions were implemented, and the altercation was reported to the Department of Public Health (DPH) within two hours resulting in the Resident experiencing psychosocial distress; and 2. For Resident #95, implement the facility's abuse policy and thoroughly investigate the Resident's missing iPad as a potential allegation of misappropriation. Findings include: Review of the facility's policy titled Abuse Identification and Reporting, dated 11/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. - All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. - Report to DPH and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of, or receiving care from, the facility. If the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but not later than two hours) after forming the suspicion. Otherwise, the report must not be made later than 24 hours after forming the suspicion. - Any suspected allegation of abuse shall be immediately reported to the Executive Director or his/her designee. - Each facility shall immediately report to the DPH, suspected resident abuse, neglect, mistreatment or misappropriation of resident property. - The Executive Director or his/her designee will immediately take action to ensure resident safety. - If the suspected perpetrator is another resident, the Director of Nursing Services or his/her designee shall separate the residents so they do not have access to each other until the circumstance of the alleged incident can be determined. - An alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1. Resident #55 was admitted to the facility in October 2017 with diagnoses including adjustment disorder with mixed anxiety and depressed mood and reaction to severe stress. Review of the 1/18/23 Minimum Data Set assessment indicated Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Resident #1A was admitted to the facility in July 2022 with diagnoses including hypertension and Crohn's disease. Review of the entire clinical record indicated Resident #1A had a history of violent behavior toward others. The Resident was discharged in February 2023. Review of the 2/1/23 MDS assessment indicated Resident #1A was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of Resident #1A's medical record indicated a 1/16/23 Nurse's Note. The note indicated Resident #55 told a nurse that his/her roommate (Resident #1A) said, If you keep me up tonight, I am going to hold a pillow over your head. Review of the Health Care Facility Reporting System (HCFRS-system used by facilities to report suspected abuse/misappropriation), dated 1/16/23 through 4/13/23, failed to indicate a report was filed regarding a resident-to-resident incident involving Residents #1A and #55 that occurred on 1/16/23. Further review of Resident #55's medical record indicated the Social Worker met with the Resident on 2/8/23 to check in on his/her psychosocial status following an incident with his/her roommate that occurred approximately three weeks ago (23 days after Resident #1A threatened Resident #55). The Social Worker documented that following her meeting with Resident #55, she informed the Administrator and Director of Nursing of the Resident's statements regarding the incident. On 2/16/23, the Social Worker accompanied Resident #55 while speaking with two community liaisons regarding the incident with Resident #1A. Subsequently, Resident #1A was discharged from the facility on 2/16/23. Resident #55 expressed nervousness, anxiety, and fear of retaliation by Resident #1A's family and friends for reporting the incident. During an interview on 4/12/23 at 10:05 A.M., the Social Services Director said she found out about Resident #55's roommate's threat to put a pillow over his/her head during morning meeting on 1/17/23. She said she met with the Administrator and Director of Nursing to update them on her meeting with Resident #55. The Social Worker said an investigation was conducted by Resident #1A's community liaisons, but she was not involved in it. She said Resident #55 and Resident #1A remained roommates until Resident #1A was discharged into the custody of the community liaisons on 2/16/23 (31 days). No protection was provided to Resident #55. The Social Worker said she made a referral for Resident #55 to be seen by the consultant psychiatric service for support. During an interview on 4/12/23 at 10:50 A.M., the Administrator said he really didn't know anything about the incident and was not sure of the details that occurred between Resident #1A and Resident #55 and would have to look into it. During an interview on 4/12/23 at 10:58 A.M., the Director of Nursing (DON) and Corporate Nurse reviewed Residents #1A and #55's medical record. The DON said the incident should have been reported to DPH immediately, investigated, and protection provided to Resident #55. She said the facility should have acted but did not. During an interview on 4/12/23 at 12:35 P.M., the Consultant Psychiatric Nurse Practitioner (NP) said he met with Resident #55 on 2/21/23 to address ongoing anxiety related to his/her roommate's threat that occurred in January 2023. The Resident said he/she felt guilt over testifying to the community liaison about the incident, but knew it was for his/her own safety. The NP said the Resident requested something for anxiety and he prescribed as needed anti-anxiety medication to treat the Resident's anxiety related to the incident. During an interview on 4/13/23 at 12:45 P.M., Resident #55 said his/her former roommate (Resident #1A) threatened to kill him/her by putting a pillow over his/her head. The Resident said he/she was scared, very anxious and afraid of his/her roommate and had to share a room with him/her for a month. The Resident said he/she had to speak to a community liaison to tell him what happened and said that experience was frightening. Shortly after speaking to the community liaison, his/her roommate was taken out of the facility. Resident #55 said he/she was scared that his/her roommate's family or friends were going to come in to pick up their belongings and take it out on me. The Resident said it still makes him/her upset every time he/she thinks about it. Resident #55 said that although he/she did not utilize the medication the NP prescribed, he/she felt better that it was available if needed. 31830 2. Resident #95 was admitted to the facility in October 2022 with diagnoses which included paranoid personality disorder and contracture of the left forearm muscle. Review of the Minimum Data Set assessment, dated 1/23/23, indicated Resident #95 was able to make self understood and able to understand others. Review of Resident #95's medical record included a Nursing Progress Note, dated 3/23/23, which indicated the Resident approached the nurses' station and told the staff member, his/her iPad (specific type of tablet computer) was missing from the dresser drawer. The Resident said he/she noticed the iPad was missing the day prior, around 3:30 P.M. The Resident said he/she did not tell anyone because they wouldn't do anything about it anyway and was filling out a grievance. The progress note indicated that the Administrator and Director of Nurses were made aware. During an interview on 4/7/23 at 3:04 P.M., Resident #95 said he/she filed a grievance regarding his/her stolen iPad which had been missing for several weeks. Resident #95 said the Administrator was aware, but the Resident had not received any information about the stolen iPad. Review of Resident #95's Grievance/Complaint, dated 3/29/23, indicated the grievance was filed by Resident #95's community case manager on behalf of Resident #95. The grievance indicated that the Resident reported to the case manager, his/her black booklet style tablet had been missing since 3/15/23. The grievance indicated that the Resident chose not to report the issue to the social worker and requested the community case manager file the grievance on his/her behalf. The grievance indicated the case manager would forward the receipt from the tablet as the case manager had helped the Resident make the purchase. Continued review of the section on the grievance form titled Findings of Investigation, indicated Resident #95 was interviewed by an unidentified person, with no identified date of the interview. The form indicated the Resident declined to have staff help search his/her room, said the tablet was missing for months, and the Resident would tell staff if he/she found it. The grievance indicated the unidentified staff member observed a Fire (specific line of tablet computers) Tablet box in an open drawer. The grievance form was signed and dated 4/6/23 by the Administrator. A posted note was stuck on the front of the grievance/complaint form, dated 4/6/23, which included the words still waiting on MFP to send receipt. The posted note was not signed. During an interview on 4/13/23 at 11:30 A.M., the Administrator said he did not have any additional information related to the grievance/complaint to provide to the surveyor. He said the community case manager provided a receipt on 4/11/23 for Resident #95's tablet to verify purchase by the Resident. The Administrator said he did not consider this grievance as an issue of misappropriation. The Administrator said if he/she had reported this concern as misappropriation, he would file the report as a missing personal item versus misappropriation. The Administrator said he would only consider a report to be misappropriation if a resident lost money or used the word stolen when referencing an item that was missing. The Administrator said if a resident used words such as, I can't find my stuff or words to that effect, he would not consider that issue to be abuse and misappropriation and would not file a report. In addition, the Administrator said if a resident used words such as, Someone stole my stuff or words to that effect, he would consider that misappropriation and would file a report with DPH. The Administrator said the word stolen would clarify to him if an issue was a reportable event or not. During a subsequent interview on 4/13/23 at 12:15 P.M., the Administrator said Resident #95 did not use the word stolen when the grievance was filed, so he did not file a report with the Department of Public Health and did not have any additional information regarding any type of investigation or statements related to Resident #95's missing tablet to provide to the surveyor. During an interview on 4/13/23 at 12:20 P.M., the Director of Social Services said although she assisted Resident #95's community case manager with the grievance, she would not consider the missing property to be considered as misappropriation as the word stolen was not used when referencing the missing tablet. She said if the word stolen was used, she would consider that to be an issue of misappropriation which would need to be reported.

Based on policy review, record review, and interview, the facility failed to thoroughly investigate an allegation of abuse, specifically, a resident-to-resident altercation, and implement protective interventions resulting in the Resident experiencing psychosocial distress for one Resident (#55), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Abuse Identification and Reporting, dated 11/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. - Any suspected allegation of abuse shall be immediately reported to the Executive Director or his/her designee. - All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. - Each facility shall immediately report to the DPH, suspected resident abuse, neglect, mistreatment or misappropriation of resident property. - The Executive Director or his/her designee will immediately take action to ensure resident safety. - If the suspected perpetrator is another resident, the Director of Nursing Services or his/her designee shall separate the residents so they do not have access to each other until the circumstance of the alleged incident can be determined. Resident #55 was admitted to the facility in October 2017 with diagnoses including adjustment disorder with mixed anxiety and depressed mood and reaction to severe stress. Review of the 1/18/23 Minimum Data Set assessment indicated Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Resident #1A was admitted to the facility in July 2022 with diagnoses including hypertension and Crohn's disease. Review of the entire clinical record indicated Resident #1A had a history of violent behavior toward others. The Resident was discharged in February 2023. Review of the 2/1/23 MDS assessment indicated Resident #1A was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of Resident #1A's medical record indicated a 1/16/23 Nurse's Note. The note indicated Resident #55 told facility staff that his/her roommate (Resident #1A) said, If you keep me up tonight, I am going to hold a pillow over your head. During an interview on 4/12/23 at 10:05 A.M., the Social Services Director said she found out about Resident #55's roommate's threat to put a pillow over his/her head during morning meeting on 1/17/23. She said she met with the Administrator and Director of Nursing to update them on her meeting with Resident #55. The Social Worker said an investigation was conducted by Resident #1A's community liaison, but she was not involved in it. She said Resident #55 and Resident #1A remained roommates until Resident #1A was discharged into the custody of the community liaisons on 2/16/23 (31 days). No protection was provided to Resident #55. During an interview on 4/12/23 at 10:58 A.M., the Director of Nursing (DON) and Corporate Nurse reviewed Residents #1A and #55's medical record. The DON said they should have investigated the allegation, put something into place to protect Resident #55 and not had them remain roommates for 31 days before Resident #1A was discharged . She said the facility should have acted but did not. During an interview on 4/12/23 at 12:35 P.M., the Consultant Psychiatric Nurse Practitioner (NP) said he met with Resident #55 on 2/21/23 to address ongoing anxiety related to his/her roommate's threat that occurred in January 2023. The Resident said he/she felt guilt over testifying to the community liaison about the incident, but knew it was for his/her own safety. The NP said the Resident requested something for anxiety and he prescribed as needed anti-anxiety medication to treat the Resident's anxiety related to the incident. During an interview on 4/13/23 at 12:45 P.M., Resident #55 said his/her former roommate (Resident #1A) threatened to kill him/her by putting a pillow over his/her head. The Resident said he/she was scared, very anxious and afraid of his/her roommate and had to share a room with him/her for a month. The Resident said he/she had to speak to a community liaison to tell him what happened and said that experience was frightening. Shortly after speaking to the community liaison, his/her roommate was taken out of the facility. Resident #55 said he/she was scared that his/her roommate's family or friends were going to come in to pick up their belongings and take it out on me. The Resident said it still makes him/her upset every time he/she thinks about it. Resident #55 said that although he/she did not utilize the medication the NP prescribed, he/she felt better that it was available if needed.

Based on record review and interviews, the facility failed to ensure for one Resident (#139), out of a total sample of 27 residents, that medications were accurately reconciled by nursing, to ensure he/she was free from a significant medication error. As a result of medication reconciliation error, Resident #139 went 29 days without being administered the correct antiseizure medication and required three transfers to the hospital emergency department and one five-day hospitalization due to the onset of seizure activity. Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, last revised April 2018, indicated use of an approved medication reconciliation form, the discharge summary from the referring facility, the most recent medication administration record, and a medication history from the resident/family were to be used to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission for accurate communication to the attending physician. The Policy further indicated that medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. The Policy indicated that medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking will continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Resident #139 was admitted to the facility in March 2023 with diagnoses including weakness and epilepsy. Review of the 3/20/23 Minimum Data Set (MDS) assessment indicated Resident #139 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15, required extensive assistance from staff for bed mobility, dressing, bathing, and toileting and had epilepsy. Review of the hospital documentation, Medication Administration Record (MAR), Transfer Report, dated 3/8/23, indicated that Resident #139's Active Medication Orders (at home) included: -Divalproex ER (brand name Depakote extended release (stays longer in the body), anticonvulsant used to treat seizures) 1500 milligrams (mg) by mouth two times a day -Carbamazepine ER (brand name Tegretol anticonvulsant used to treat seizures) 1200 mg two times a day. Further review of the medical record indicated a verbal order was obtained from the Nurse Practitioner for Divalproex ER 1500 mg by mouth two times a day and Carbamazepine ER 1200 mg two times a day on 3/14/23. The Tegretol order was transcribed in the medical record for standard immediate release and not extended release as indicated by the NP's verbal order. Review of Resident #139's March 2023 MAR indicated the inaccurate order for immediate release Tegretol 1200 mg two times a day was administered 33 times instead of Tegretol ER. Further review of Resident #139's medical record and documentation related to his/her admission indicated there was no documentation to support that a medication reconciliation was performed by nursing, and the facility was unable to provide the surveyor with a copy of Resident #139's medication reconciliation form that should have been completed by nursing upon admission. The American Society of Health-System Pharmacists, Inc. (website) Tegretol ER (an anticonvulsant or antiepileptic drug) indicated it is used to prevent and control seizures. It works by reducing abnormal electrical activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Seizures can become worse when the drug is suddenly stopped. If you miss a dose, take it as soon as you remember. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. The extended-release tablet does not dissolve in the stomach after swallowing. It slowly releases the medicine as it passes through your digestive system. Review of a 3/20/23 Nurse's Progress Note indicated Resident #139's Neurology NP called the facility with an order to increase the dose of Depakote ER to 2000 mg twice daily and obtain Valproic Acid level in two weeks. There was no evidence in the medical record that the Resident's current medication orders for antiseizure medication was reviewed with the NP. The incorrect medication orders for immediate release Tegretol was continued. Review of 3/31/23 lab results indicated Resident #139's Valproic Acid level was flagged high and was greater than 150 ug (micrograms)/mL (milliters) with a reference range of 50-100; Tegretol level was flagged as critically high and was 14.0 ug/mL with a reference range of 4.0-10.0. Review of Resident #139's Nursing Progress Notes indicated that Resident #139 required transfers to the emergency room following seizure activity on 3/19/23, 4/3/23, and 4/6/23. Resident #139 was hospitalized from 4/6/23 to 4/11/23 for multiple seizures. Upon return to the facility from each visit to the hospital, the facility failed to ensure a medication reconciliation was conducted to ensure the correct medication was resumed/ordered. The inaccurate order for Resident #139's Tegretol was not identified by the facility until 29 days after Resident #139's admission, when the surveyor brought the error to the Physician's attention. During interviews on 4/12/23 at 11:45 A.M. and 4/14/23 at 1:30 P.M., Unit Manager #1 said when Resident #139 was admitted to the facility, he/she came directly from the emergency room and there was no medication list to reconcile because he/she was treated in the emergency room and was not actually admitted to the hospital. Unit Manager #1 said she called the Resident's Neurologist in the community to request a medication list. She said she received the Neurologist's note, reviewed the medications with the Resident's attending Physician's Nurse Practitioner (NP) and entered the orders into the electronic medical record. She said she did not utilize a medication reconciliation form per facility policy. The surveyor and Unit Manager #1 reviewed the Neurologist's note, and she confirmed that the medication list she reviewed with the Resident's NP included Depakote ER 500 mg 3 tabs (1500 mg) twice a day and Tegretol ER 200 mg 6 tabs twice a day. She was not aware that the Tegretol orders were entered into the electronic medical record incorrectly. During an interview on 4/12/23 at 12:19 P.M., the surveyor reviewed Resident #139's medical record with Physician #1. The Physician said that Resident #139's admission medication orders that were authorized verbally, were not entered accurately into the electronic medical record upon admission. He said a medication reconciliation should have been done by the nurse upon the Resident's admission to the facility and each time the Resident returned from the hospital.

Based on observation, interview, and record review, the facility failed to notify the physician of changes in condition, to re-evaluate the potential need to alter the treatment plan for three Residents (#53, #44, and #34), from a total sample of 27 residents. Specifically, the facility failed to notify the primary physician when: 1. Resident #53 had changes to a right foot lesion including signs and symptoms of infection; 2. Resident #44 received critically high laboratory values; and 3. Resident #34 had a recommendation for eye drops. Findings include: 1. Resident #53 was admitted to the facility in September 2010 with a diagnosis of skin cancer. Review of the Physician's Orders included an order initiated on 4/4/22 to monitor the right foot lesion every shift and to notify the Physician or Nurse Practitioner if abnormalities or signs and symptoms of infection are noted. Review of the Treatment Administration Record for 4/1/23 through 4/6/23 included a check mark on every shift by the nurse to indicate the foot lesion was monitored. On 4/6/23 at 9:39 A.M., the surveyor observed Resident #53 to be lying in bed. The surveyor observed a flat, golf ball sized open area to the right dorsal foot. The observed area had dried bloody drainage dripping from the base of the wound to the bottom of the foot. There were multiple spots of dried blood outside of the wound bed. The wound bed was observed to be a beefy red in the top portion and to have darkened areas towards the bottom portion. The surrounding tissue was observed to be reddened approximately a half inch around the wound. On 4/6/23 at 11:30 A.M., the surveyor observed the Resident in bed. The surveyor observed the right foot to no longer have dried bloody areas surrounding the wound and no drainage dripping to the bottom of the foot but continued to have reddened tissue surrounding the lesion. The foot was now resting on a disposable incontinent pad. On 4/6/23 at 4:04 P.M., the surveyor observed the Resident in bed. The wound had two areas of bloody drainage, one trailing to the heel and one trailing to the bottom of the foot. There was dried blood covering the ankle. The surrounding tissue continued to be red. There were blood-soaked areas on the incontinent pad. Review of the Nursing Progress Notes and the Physician's Orders from 3/29/23 through 4/6/23 failed to include any documentation of the wound description, surrounding area redness, or physician notification of changes as indicated in the order. During an interview on 4/12/23 at 11:04 A.M., Nurse #7 said she had worked from 7:00 A.M. to 7:00 P.M. on 4/6/23 with Resident #53. She said she was unfamiliar with the baseline of the skin lesion to the right foot for Resident #53 and did not know if there were any changes from the baseline. She said on 4/6/23 she had used a wound cleanser on the right foot lesion, and she was not sure if there was an order for this. She said she had not noticed the reddened surrounding tissue and had not contacted the physician, as indicated in the order. On 4/7/23 at 7:03 A.M., the surveyor observed Resident #53 lying in bed with their left heel resting on top of their right foot. The skin lesion to the right foot was observed to have bloody drainage including dripping blood trailing to the heel and four trails of blood to the bottom of the foot and then pooling on the blanket below the foot. The surrounding tissue continued to be reddened. During an interview on 4/7/23 at 9:05 A.M., Nurse #6 said she cared for Resident #53 on Tuesday 4/4/23 and the right foot lesion had some bloody drainage on Tuesday and said based on observation with surveyor at this time, the bloody drainage had increased. She said the current plan for the skin lesion was that when Resident #53 was cleaned up by the Certified Nursing Assistants, they would notify the nurse who would clean the wound with a wound cleanser. She said she had not contacted the physician either on 4/4/23 with the change or this morning. Review of the Physician's Progress Note written by the Nurse Practitioner, dated 4/7/23, indicated Resident #53 was seen for a wound evaluation of a chronic wound to the right outer ankle (right foot lesion) with surrounding erythema (reddening of the skin). The Nurse Practitioner noted a diagnosis of cellulitis (infection of the skin) with a new order for Doxycycline (antibiotic) 100 milligrams twice per day for 10 days and a new physician order dated 4/7/23 to culture the wound. During an interview on 4/12/23 at 11:30 A.M., the Director of Nurses said the expectation would be that the nurses would have notified the physician of any changes to the area and obtained an order for a dry protective dressing. During an interview on 4/13/23 at 4:04 P.M., the Assistant Director of Nurses said there was no baseline of the right foot skin lesion documented in the medical record for the nurses to determine if there was a change in the skin lesion per the physician's order. She said the nurse should have been able to identify the reddened surrounding tissue and should have notified the physician of the changes. 2. Resident #44 was admitted to the facility in January 2023. Review of the medical record indicated Resident #44 had a laboratory draw on 4/4/23 for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC). Review of the results indicated Resident #44 had the following abnormal results: Immature Grans % (percentage of type of white blood cells): critically high BUN (kidney function): high Creatine (kidney function): high Glucose (blood sugar): high Total Protein: low Bilirubin Total (checks liver health): high GFR (checks kidneys): low RBC (red blood cells): low HGB (hemoglobin level): low HCT (level of healthy red blood cells): low MCV (size of red blood cells): high RDW-SD (variation in size of red blood cells): high Platelet Count: Low Lymphs (type of immune cell): low ABS Immature Grans (white blood cell level): high Review of the paper and electronic medical record on 4/13/23, including the printed laboratory results and the nursing progress notes, failed to indicate a physician was notified of the laboratory results. During an interview on 4/13/23 at 9:49 A.M., Nurse #10 said there was no indication the physician was notified of the abnormal laboratory results, including the critically high result. During an interview on 4/13/23 at 2:38 P.M., the Director of Nurses said she had spoken with the Nurse Practitioner for Resident #44 who was unaware of the critical laboratory results and there was no indication a Physician was notified of the results by the nursing staff. 3. Resident #34 was admitted to the facility in October 2022 with a diagnosis of legal blindness. Review of the consultant Eye Care Group visit, dated 11/7/22, indicated Resident #34 was seen by an Optometrist for Resident complaints of persistent dry eye and morning eye debris. The plan indicated a new medication recommendation for Refresh Tears ophthalmic solution, apply 1 drop to both eyes, twice daily for indefinite period. Review of the medical record including Medication and Treatment Administration Records did not indicate the Refresh Tear drops were administered. Review of the nursing progress notes did not indicate the attending physician or Nurse Practitioners were notified of the recommended change in treatment. On 4/12/23 at 4:12 P.M., the surveyor requested information regarding the physician notification for the recommended eye drops. During an interview on 4/12/23 at 4:53 P.M., the Staff Development Coordinator (SDC) reviewed the medical record for Resident #34 and said the recommendation for eye drops had not been addressed. The SDC said she contacted the Nurse Practitioner today and confirmed that neither the Nurse Practitioner nor the physician were previously made aware of the recommendation.

Based on observations, interviews, and record review, the facility failed to ensure quality care was provided to one Resident (#53), out of a total sample of 27 residents. Specifically, the facility failed to monitor, document, and assess the Resident's identified foot lesion, resulting in an infection. Findings include: Review of the facility's Wound Documentation Skills Checklist, undated, indicated the following: -this table represents wound document parameters that must be met in order for the nursing staff to provide quality nursing care -the skills check list provides an evaluation tool to measure and record each step of the skill that staff is expected to successfully perform in order to safely identify and document wounds including: type, location, partial or full thickness, size, undermining/tunneling/sinus tracts, exudate type and amount, odor, description of characteristics of wound bed tissue, wound edges, surrounding tissue, indicators of infection, pain, interventions for healing, conditions that would affect wound healing, any topical treatments and response to treatments. Resident #53 was admitted to the facility in September 2010 with diagnoses of skin cancer, schizophrenia, and dementia with behaviors. Review of the medical record indicated Resident #53 had a history of a skin lesion to the right dorsal (top) foot with a related hospital admission in June 2021. The Hospital Discharge Summary indicated the court appointed guardian declined aggressive treatment and the hospital recommended to treat the skin lesion conservatively with a dressing to the area to avoid any trauma. Review of the care plans for Resident #53 included: -Focus of pain with an alteration in comfort related to cancer of the skin including the right foot -Goal of the Resident being able to verbalize having no pain within 20 minutes of receiving as needed medication. -Interventions included educating Resident and family about comfort measures, analgesic medications and discussing fears/concerns regarding pain, comfort and disease process, and to monitor and report to nurse signs and symptoms of pain and worsening pain. The care plans did not include any other goals or interventions regarding the skin lesion to the right foot. Review of the Physician's Orders included an order initiated on 4/4/22 to monitor the right foot lesion every shift and to notify the Physician or Nurse Practitioner if abnormalities or signs and symptoms of infection are noted. Review of the Treatment Administration Record for 4/1/23 through 4/6/23 included a check mark on every shift by the nurse to indicate the foot lesion was monitored. The order did not include a description of the foot lesion (wound bed, size, shape, drainage, condition of surrounding tissue.) As of 4/6/23 there were no additional physician's orders regarding the right foot lesion. On 4/6/23 at 9:39 A.M., the surveyor observed Resident #53 lying in bed. The surveyor observed a flat, golf ball sized open area to the right dorsal foot. The observed area had dried bloody drainage dripping from the base of the wound to the bottom of the foot. There were multiple spots of dried blood outside of the wound bed. The wound bed was observed to be a beefy red in the top portion and to have darkened areas towards the bottom portion. The surrounding tissue was observed to be reddened approximately half inch around the wound. The foot was resting on a folded blanket. On 4/6/23 at 11:30 A.M., the surveyor observed the Resident in bed. The surveyor observed the right foot to no longer have dried bloody areas surrounding the wound and no drainage dripping to the bottom of the foot but continued to have reddened tissue surrounding the lesion. The foot was now resting on a disposable incontinent pad. On 4/6/23 at 4:04 P.M., the surveyor observed the Resident in bed. The wound had two areas of bloody drainage, one trailing to the heel and one trailing to the bottom of the foot. There was dried blood covering the ankle. The surrounding tissue continued to be red. There were blood-soaked areas on the incontinent pad. Review of the Wound Consultant's Wound Evaluation and Management Summary and Skin Evaluations from 3/1/23 through 4/6/23 failed to include any documentation to describe the right foot lesion. Review of the Nursing Progress Notes indicated on 3/10/23 the right foot lesion was dry, scabbed with no signs of infection and on 3/29/23 the right foot lesion was chronic, large dry scab without signs or symptoms of infection. There were no descriptions of the wound between 3/10/23 and 3/29/23 or after 3/29/23. Review of the Nursing Progress Notes and Physician's Orders from 3/29/23 through 4/6/23 failed to include any documentation of the wound description, surrounding area redness or physician notification as indicated in the order. During an interview on 4/12/23 at 11:04 A.M., Nurse #7 said she had worked from 7:00 A.M. to 7:00 P.M. on 4/6/23 with Resident #53. She said she worked for an agency and was not employed directly by the facility and had not worked on this unit in a couple of months. She said she was unfamiliar with the baseline of the skin lesion to the right foot for Resident #53 and did not know if there were any changes from the baseline. She said on 4/6/23 she had used a wound cleanser on the right foot lesion, and she was not sure if there was an order for this. She said she had not noticed the reddened surrounding tissue and had not contacted the physician, as indicated in the order. On 4/7/23 at 7:03 A.M., the surveyor observed Resident #53 lying in bed with their left heel resting on top of their right foot. The skin lesion to the right foot was observed to have bloody drainage including dripping blood trailing to the heel and four trails of blood to the bottom of the foot and then pooling on the blanket below the foot. The surrounding tissue continued to be reddened. During an interview on 4/7/23 at 9:05 A.M., Nurse #6 said she regularly worked at the facility and was familiar with Resident #53 and the chronic right foot lesion. She said she cared for Resident #53 on Tuesday 4/4/23 and the right foot lesion had some bloody drainage on Tuesday and said based on observation with surveyor at this time, the bloody drainage had increased. She said the current plan for the skin lesion was that when Resident #53 was cleaned up by the certified nursing assistants, they would notify the nurse who would clean the wound with a wound cleanser. She said there were no treatments provided to the lesion as the Resident was on hospice and did not want any biopsies or extractions. During an interview on 4/7/23 at 11:12 A.M., Nurse #7 said she had contacted the Nurse Practitioner who ordered a wound cleanser and Cavilon spray (a liquid barrier film that dries quickly to form a breathable, transparent coating on the skin) and the Resident would be seen by the Nurse Practitioner for the reddened surrounding tissue which may indicate an infection. During an interview on 4/7/23 at 2:35 P.M., the Wound Physician Consultant said she did not follow the right foot skin lesion for Resident #53 as the family did not want any treatments. She said the Resident was previously followed for this area and when the skin lesion is dry and crusted it is best to be left open to air. She said she could recommend a powder to dry the area, but the family declined treatment. She said the Resident had a history of pulling off wound dressings. The wound physician said she has continued to recommend wound dressings to other open skin areas, but no longer followed or monitored this open skin lesion. During an interview on 4/7/23 at 2:35 P.M., Nurse #7 said the surrounding tissue of the skin lesion looked worse than it had that morning when she cleaned the area. During an interview on 4/7/23 at 2:45 P.M., the court appointed guardian for Resident #53 said due to the overall decline of the Resident through the previous years the decision had been made not to treat the cancer aggressively. She said that did not mean that wound dressings or recommendations for wound care could not be followed. She said the main goal was for the Resident to be comfortable. She said she had spoken with Nurse #7 earlier in the week who had notified her that the right foot skin lesion was bleeding. Review of the Physician's Progress Note, dated 4/7/23, indicated Resident #53 was seen for a wound evaluation of a chronic wound to the right outer ankle (right foot lesion) with surrounding erythema (reddening of the skin). The Nurse Practitioner noted a diagnosis of cellulitis (infection of the skin) with a new order for Doxycycline (antibiotic) 100 milligrams twice per day for 10 days and a new physician order dated 4/7/23 to culture the wound. During an interview on 4/12/23 at 11:30 A.M., the Director of Nurses said the expectation would be that the nurses would have notified the physician of any changes to the area and obtained an order for a dry protective dressing, regardless of the behaviors (of removing a dressing) for Resident #53. During an interview on 4/13/23 at 4:04 P.M., the Assistant Director of Nurses said there was no baseline of the right foot skin lesion documented in the medical record for the nurses to determine if there was a change in the skin lesion per the physician's order. She said the nurse should have been able to identify the reddened surrounding tissue and should have notified the physician of the changes.

Based on interviews and record review, the facility failed to ensure the physician included an evaluation of the resident's condition and total program of care, including the accuracy of orders for medications, for one Resident (#139), out of a total sample of 27 residents, which resulted in the Resident being administered the wrong anti-seizure medication for 28 days, had three transfers to the hospital emergency department and one five-day hospitalization due to the onset of seizure activity. Findings include: Resident #139 was admitted to the facility in March 2023 with diagnoses including weakness and epilepsy. Review of the 3/20/23 Minimum Data Set (MDS) assessment indicated Resident #139 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15, required extensive assistance from staff for bed mobility, dressing, bathing and toileting and had epilepsy. Review of the hospital documentation, Medication Administration Record (MAR), Transfer Report, dated 3/8/23, indicated that Resident #139's Active Medication Orders (at home) included: -Divalproex ER (brand name Depakote extended release (stays longer in the body), anticonvulsant used to treat seizures) 1500 milligrams (mg) by mouth two times a day -Carbamazepine ER (brand name Tegretol anticonvulsant used to treat seizures) 1200 mg two times a day. Review of a 2/8/23 Neurology progress note indicated Resident #139's home medications were Divalproex ER 1500 mg by mouth two times a day and Carbamazepine ER 1200 mg two times a day. The neurology note indicated Resident #139's last seizure was on 10/7/22. Further review of the medical record indicated a verbal order was obtained from the Nurse Practitioner for Divalproex ER 1500 mg by mouth two times a day and Carbamazepine ER 1200 mg two times a day on 3/14/23. Review of the March 2023 Physician's Orders indicated: - Depakote ER 1500 mg two times a day - Tegretol 1200 mg two times a day The Tegretol order was transcribed in the medical record for standard immediate release and not extended release as indicated by the NP's verbal order. Review of the medical record indicated a 3/15/23 New Admission History & Physical Note, signed by Resident #139's Attending Physician on 3/22/23. The Physician indicated he reviewed the Resident's medications, Medication Administration Record (MAR), hospital discharge summary, and reviewed the plan of care with nursing staff. The Physician's note failed to indicate he identified the incorrect medication order for Tegretol. Review of a subsequent New Admission History & Physical Note, dated 4/5/23 and signed by the Physician on 4/10/23, indicated he reviewed the Resident's medications, MAR, hospital discharge summary, and reviewed the plan of care with nursing staff. The Physician's note failed to indicate he identified the incorrect medication order for Tegretol. During an interview on 4/12/23 at 12:19 P.M., the surveyor reviewed Resident #139's medical record with Physician #1. The Physician said he did see Resident #139 on 3/15/23 and 4/5/23, but he did not review the Resident's medical record. He said when he comes into the facility, he speaks to nursing staff and takes their information as they relay it about the Resident and uses that information in his assessments. He said he did not know Resident #139 was being administered Tegretol immediate release and not Tegretol Extended Release. He said Resident #139 had been having uncontrolled seizures because he/she had been receiving the wrong medication since admission to the facility.

Based on record review and interviews, the facility failed to ensure the consultant pharmacists identified and reported irregularities (use of a medication that is inconsistent with accepted standards of practice) for two Residents (#139 and #70), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #139, to ensure the Consultant Pharmacists reviewed the Resident's medical record and identified and reported an irregularity regarding inaccurate transcription of an order for an anti-seizure medication upon admission and monthly review which resulted in the Resident receiving the wrong medication for 28 days, had three transfers to the hospital emergency department and one five-day hospitalization due to the onset of seizure activity; and 2. For Resident #70, a. to ensure the Consultant Pharmacist identified and reported an irregularity regarding the continued use of an antibiotic, and b. the attending Physician failed to document that an identified irregularity of blood thinner use had been reviewed and failed to document the rationale for the continued use. Findings include: Review of the facility's policy, Pharmscript-Medication Regimen Review, dated 8/2020, included but was not limited to: Policy: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Procedures: -If a consultation is needed when the pharmacist is off-site, the consultant pharmacist works with facility personnel and electronic records to gather pertinent information related to the resident's status and/or request for consultation. -The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents. -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and/or prescriber as appropriate. -Recommendations are acted upon and documented by the facility staff and/or prescriber. 1. Resident #139 was admitted to the facility in March 2023 with diagnoses including weakness and epilepsy. Review of the 3/20/23 Minimum Data Set (MDS) assessment indicated Resident #139 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15, required extensive assistance from staff for bed mobility, dressing, bathing, and toileting and had epilepsy. Review of the hospital documentation, Medication Administration Record (MAR), Transfer Report, dated 3/8/23, indicated that Resident #139's Active Medication Orders (at home) included: -Divalproex ER (brand name Depakote extended release (stays longer in the body), anticonvulsant used to treat seizures) 1500 milligrams (mg) by mouth two times a day -Carbamazepine ER (brand name Tegretol anticonvulsant used to treat seizures) 1200 mg two times a day. Further review of the medical record indicated a verbal order was obtained from the Nurse Practitioner for Divalproex ER 1500 mg by mouth two times a day and Carbamazepine ER 1200 mg two times a day on 3/14/23. The Tegretol order was transcribed in the medical record for standard immediate release and not extended release as indicated by the NP's verbal order. Review of a 3/15/23 Interim Medication Regimen Review, signed by Pharmacist #3 indicated Based on information submitted for review, I have no recommendations at this time. The pharmacist failed to identify and report the inaccurate transcription of the Resident's Tegretol. During a telephone interview on 4/14/23 at 10:38 A.M., Pharmacist #3 said he is responsible for standard admission medication regimen reviews for the facility, and he conducted an admission medication review for Resident #139 off-site on 3/15/23. The pharmacist said he reviewed the Resident's medical record remotely, specifically physician's orders and the MAR, and found no irregularities. The surveyor asked him if he reviewed hospital documentation including hospital medication orders as a part of his review and he said he did not. On 3/19/23 at approximately 3:50 P.M., Resident #139 had a seizure and was transferred to the hospital. Hospital documentation indicated the Resident's home medication list included Depakote ER and Tegretol ER (not immediate release Tegretol). The Resident returned to the facility with no new orders and the previous medication orders were resumed (including the incorrect medication orders for immediate release Tegretol). On 4/3/23, Resident #139 was transferred to the hospital for seizure-like activity. The Resident returned with no new orders and the previous medication orders were resumed (including the incorrect medication orders for immediate release Tegretol). Review of a 4/4/23 Medication Regimen Review indicated: -Based upon the information available at the time of the review and assuming the accuracy and completeness of such information, it is my personal judgement that at such time the resident's medication regimen contained no new irregularities. For purposes of the foregoing statement, the term irregularity means an event or circumstance that is substantially inconsistent with customary, accepted clinical approaches to providing pharmaceutical products and services or that could reasonably be expected to impede or interfere with the achievement of intended or reasonably expected outcomes. The pharmacist failed to identify and report the inaccurate transcription of the Resident's Tegretol following two hospital visits for seizures. Review of the medical record indicated on 4/6/23, Resident #139 suffered multiple seizures, was transferred to the hospital, and admitted for five days. During a telephone interview on 4/13/23 at 12:01 P.M., Pharmacist #1 said she reviewed Resident #139's medical record when she conducted her MRR on 4/4/23 and did not pick up any irregularities with the Resident's orders. During an interview on 4/12/23 at 12:19 P.M., the surveyor reviewed Resident #139's medical record with Physician #1. He said the medication transcription error should have been picked up each time the Resident returned from the hospital and medication orders were reviewed. 36542 2. Resident #70 was admitted to the facility in February 2015 with a diagnosis of diabetes and was readmitted with a diagnosis of a foot wound infection in December 2022. a. Review of the Hospital Discharge Summary, dated 12/6/22, indicated Resident #70 had a worsening left foot ulcer with suspicion of possible cellulitis (bacterial infection of the skin) without osteomyelitis (bone infection). The Resident was seen by Infectious Disease, received IV (intravenous) antibiotics and then upon discharge would switch to oral antibiotics for a total of 10 days. Review of the discharge medications indicated the following orders: Ceftin (antibiotic) 500 milligrams (mg) every 12 hours, for a total of 20 doses (10 days) and Doxycycline (antibiotic) 100 mg twice per day for a total of 20 doses (10 days). Review of the Medication Administration Record (MAR) indicated Resident #70 had an order dated 12/6/22 for Doxycycline 100 mg two times per day for antibiotic treatment for foot wounds. Review of the April 2023 MAR indicated Resident #70 continued to receive Doxycycline 100 mg twice per day and now indicated no stop date. Review of the monthly Medication Regimen Reviews, dated 1/3/23, 2/1/23, 3/1/23, and 4/4/23, failed to include the reporting of irregularities related to the continued use of an antibiotic, without duration. During an interview on 4/13/23 at 12:12 P.M., the Consultant Pharmacist said during the Medication Regimen Review she reviews the antibiotic use to ensure the antibiotic stewardship program is being followed. She said she will usually request documentation for continuation and need for antibiotic use, unless it's already in the medical record. She said she had not seen or requested documentation of a continued infection for Resident #70 and had assumed the wound infection continued. She said she had not made any recommendations regarding the extended use of the antibiotic for four months because it contained the words no stop date and she did not want to interfere with care. b. Review of the electronic medical record indicated the Consultant Pharmacist made a recommendation regarding an irregularity on 1/3/23 and indicated to see the recommendation. Review of the paper and electronic medical record on 4/12/23 failed to include the Consultant Pharmacist Recommendation to Prescriber form and the form was requested from the Director of Nurses. Review of the Consultant Pharmacist Recommendation, dated 1/3/23, indicated Resident #70 was currently receiving Lovenox (blood thinner) therapy and to review the order for a stop date based on diagnosis, clinical guidelines, or patient mobility. The form indicated the Medication Regimen Review was conducted on 1/3/23 and the form was printed on 1/28/23. The prescriber response box was checked off as disagree with a date of 1/17/23 handwritten next to it and indicated there was an upcoming appointment and to follow up at Vascular. The form was not signed and did not indicate who made the decision. During an interview on 4/13/23 at 8:57 A.M., the Director of Nurses said this was the only copy of the form she had and there was no signed copy from a physician. She said she had called the nurse on the unit of Resident #70 and the nurse had said the plan was to wait for Vascular, she said she did not know which Physician made this determination. The surveyor requested documentation to indicate the attending Physician had reviewed the irregularity and had documented their rationale in the medical record. During an interview on 4/13/23 at 2:46 P.M., the Director of Nurses said there was no documentation in the medical record regarding the continued use of the Lovenox.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive assistance of two staff members with the use of sit-to-stand mechanical lift for transfers, the Facility failed to ensure staff implemented and followed interventions from Resident #1's plan of care related to transfers, when on 09/30/22, Certified Nurse Aide (CNA) #1 who was assigned to care for Resident #1, attempted to transfer him/her out of bed and into his/her wheelchair using a sit-to-stand mechanical lift without another staff member present to provide assistance, Resident #1 fell on to the floor and the mechanical lift landed on top of him/her. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a left ankle fracture. Findings include: Review of the Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised 11/2017, indicated that a comprehensive person-centered care plan will be developed and implemented for each resident. The Policy indicated that care plans include measurable objectives and timeframe's and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the Facility's Policy, titled Lifting Machine Using a Mechanical Lift, dated as revised 4/2018, indicated two staff members are needed to safely move a resident with a mechanical lift. The Policy indicated to make sure the sling is securely attached to the clips and that it is properly balanced and to support the resident as he or she is moved. Resident #1 was admitted to the Facility in December 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/13/22, indicated that he/she required extensive assistance of two staff members for transfers. Review of Resident #1's Nursing Evaluation, dated 09/28/22, indicated that he/she was at risk for falls, was dependent for transfers and required two staff members with a mechanical lift. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, (confirmed with the Director of Nurses as the plan of care that was in effect at the time of the fall) indicated that he/she was dependent on two staff members with sit-to-stand mechanical lift for transfers. Review of Resident #1's Care Kardex (used by Certified Nurse Aides to determine residents level of care), dated as of 03/16/22 (confirmed with the Director of Nurses as the Resident Kardex that was in effect at the time of the fall), indicated that he/she was dependent on two staff members with sit-to-stand mechanical lift for transfers. During an interview on 10/25/22 at 11:10 A.M., Resident #1 said that CNA #1 transferred him/her onto the sit-to-stand mechanical lift and as she was turning the mechanical lift, it tilted sideways, and threw him/her on the floor. Resident #1 said after he/she fell on to the floor, the lift then landed on top of him/her. Resident #1 said that he/she could not move, that CNA #1 seemed like she was in shock and he/she yelled at her (CNA #1) to get help. Resident #1 said there is supposed to be two CNA's using the mechanical lift when they transfer him/her. Resident #1 said that when he/she fell it caused a fracture to his/her left ankle. Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 10/04/22, indicated that on 09/30/22 at approximately 10:15 A.M., Resident #1 had a fall during a transfer in his/her room and the assigned CNA (later identified as CNA #1) notified staff of the incident. The Report indicated that Resident #1 was lying on his/her back on the floor, his/her left leg was turned (rotated) outward and he/she complained of pain in that area. The Report indicated the physician was notified and Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned to the Facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Fall Incident Report, dated 09/30/22, indicated that at approximately 10:15 A.M., the nurse was called by Resident #1's CNA (CNA #1) to his/her room and CNA #1 said that Resident #1 fell . Resident #1 was found lying on the floor in front of his/her wheelchair. The Report indicated that Resident #1 complained of pain to his/her left leg upon movement and his/her leg was externally rotated. The Report indicated that Resident #1 said CNA #1 was transferring him/her in the sit-to-stand mechanical lift and it tipped over falling on top of him/her. The Report indicated that the Nurse Practitioner was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Review of a Nurse Progress Note, dated 09/30/22, indicated that at approximately 10:15 A.M., the nurse was called by Resident #1's CNA (CNA #1) into his/her room and CNA #1 said that Resident #1 fell . The Note indicated that the nurse found him/her lying on the floor in front of his/her wheelchair. During an interview on 10/25/22 at 1:17 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and said she found him/her lying on the floor next to the heat register, with the back of his/her head against the seat of his/her wheelchair. Nurse #1 said that Resident #1 required the assistance of two staff members with use of the sit-to-stand mechanical lift, and said she was not aware that CNA #1 attempted to transfer Resident #1 by herself. Review of CNA #1's Written Witness Statement, dated 09/30/22, indicated that she transferred Resident #1 out of his/her bed with the sit-to-stand mechanical lift. The Statement indicated that she (CNA #1) turned the mechanical lift, Resident #1 became unsteady, and the mechanical lift tipped over sideways, and Resident #1 fell . The Statement indicated that she (CNA #1) could not stop him/her from falling. During an interview on 10/26/22 at 1:23 P.M., Certified Nurse Aide #1 said that she was aware that Resident #1 required two staff members with sit-to-stand mechanical lift for transfers, and said that on 9/30/22, she transferred Resident #1 onto the sit-to-stand mechanical lift alone, without the assistance of another staff member. CNA #1 said that she did not follow Resident #1's plan of care. During an interview on 10/25/22 at 2:47 P.M., the Director of Nurses (DON) said that Resident #1's plan of care indicated he/she was dependent on two staff members with sit-to-stand mechanical lift for transfers and said that CNA #1 did not follow Resident #1's plan of care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive assistance of two staff members with the use of sit-to-stand mechanical lift for transfers, the Facility failed to ensure he/she was provided the necessary level of staff assistance required to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 09/30/22, Certified Nurse Aide (CNA) #1 who was assigned to care for Resident #1, attempted to transfer him/her out of bed into his/her wheelchair using a sit-to-stand mechanical lift without another staff member present to provide assistance, and during the transfer the mechanical lift became unsteady, started to lean to one side, and tipped over. Resident #1 fell to the floor and the mechanical lift landed on top of his/her body. Resident #1 complained of pain to his/her left leg, he/she was transferred to the Hospital Emergency Department for evaluation, and diagnosed with a left ankle fracture. Findings include: Review of the Facility's Policy, titled Lifting Machine Using a Mechanical Lift, dated as revised 4/2018, indicated two staff members are needed to safely move a resident with a mechanical lift. The Policy indicated to make sure the sling is securely attached to the clips and that it is properly balanced and to support the resident as he or she is moved. Review of the Facility's Policy, titled Safe Lifting and Movement of Residents, dated as revised 5/2018, indicated that in order, to protect the safety and well-being of residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 10/04/22, indicated that on 09/30/22 at approximately 10:15 A.M., Resident #1 had a fall during a transfer in his/her room and the assigned CNA (later identified as CNA #1) notified staff of the incident. The Report indicated that Resident #1 was lying on his/her back on the floor, his/her left leg was turned (rotated) outward and he/she complained of pain in that area. The Report indicated the physician was notified and Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned to the Facility with a diagnosis of left distal tibia and fibula fracture (fracture of the ankle) and a cast was applied to his/her left lower extremity. During an interview on 10/25/22 at 11:10 A.M., Resident #1 said that CNA #1 transferred him/her with the sit-to-stand mechanical lift and as she was turning the mechanical lift, it tilted sideways and threw him/her on the floor, Resident #1 said after he/she fell the lift landed on top of him/her. Resident #1 said that he/she could not move, that CNA #1 seemed like she was in shock and said that he/she yelled at her (CNA #1) to get help. Resident #1 said there is supposed to be two CNA's using the mechanical lift when they transfer him/her. Resident #1 said that when he/she fell it caused a fracture to his/her left ankle. Resident #1 was admitted to the Facility in December 2021, diagnoses included left side [CONDITION(S)] and [CONDITION(S)] (muscle weakness and [CONDITION(S)]) following cerebral infarction (stroke), lack of coordination, unsteadiness on feet, abnormalities of gait and mobility, and contracture of left hand. Review of Resident#1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/13/22, indicated that Resident #1 required extensive assistance of two staff members for transfers. Review of Resident #1's Nursing Evaluation, dated 09/28/22, indicated that he/she was at risk for falls, was dependent for transfers and required two staff members with a mechanical lift. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, (confirmed with the Director of Nurses as the plan of care that was in effect at the time of the fall) indicated that he/she was dependent on two staff members with sit-to-stand mechanical lift for transfers. Review of Resident #1's Care Kardex (used by Certified Nurse Aides to determine residents level of care), dated as of 03/16/22 (confirmed with the Director of Nurses as the Resident Kardex that was in effect at the time of the fall), indicated that he/she was dependent on two staff members with sit-to-stand mechanical lift for transfers. Review of Resident #1's Fall Incident Report, dated 09/30/22, indicated that at approximately 10:15 A.M., the nurse was called by Resident #1's CNA (CNA #1) to his/her room and CNA #1 said that Resident #1 fell . Resident #1 was found lying on the floor in front of his/her wheelchair. The Report indicated that Resident #1 complained of pain to his/her left leg upon movement and his/her leg was externally rotated. The Report indicated that Resident #1 said CNA #1 was transferring him/her in the sit-to-stand mechanical lift and it tipped over falling on top of him/her. The Report indicated that the Nurse Practitioner was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Review of a Nurse Progress Note, dated 09/30/22, indicated that at approximately 10:15 A.M., the nurse was called by Resident #1's CNA (CNA #1) into his/her room and CNA #1 said that Resident #1 fell . The Note indicated the nurse found him/her lying on the floor in front of his/her wheelchair. The Note indicated that Resident #1 complained of pain to his/her left leg upon movement and his/her left leg was externally rotated. The Note indicated that the Nurse Practitioner was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. During an interview on 10/25/22 at 1:17 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and said she found him/her lying on the floor next to the heat register, with the back of his/her head against the seat of his/her wheelchair. Nurse #1 said that she and Nurse #2 assessed Resident #1, that his/her left leg was externally rotated and when he/she put pressure on his/her left foot he/she yelled it hurts. Nurse #1 said that Resident #1 told her the lift fell on top him/her and broke his/her leg. Nurse #1 said that the mechanical lift belt was still clipped around Resident #1's upper body, but that the mechanical lift was not in his/her room when she entered. Nurse #1 said that Resident #1 required the assistance of two staff members with use of the mechanical sit-to-stand lift, and said she was not aware that CNA #1 attempted to transfer Resident #1 by herself until Resident #1 told her about how he/she fell . During an interview on 10/26/22 at 1:11 P.M., Nurse #2 said she and Nurse #1 were at the nurse's station when CNA #1 approached them and said Resident #1 was on the floor. Nurse #2 said upon entering Resident #1's room he/she was lying on the floor next to the heat register. Nurse #2 said Resident #1 told them that the mechanical lift tipped over and fell on top of him/her, and that Resident #1 then said that girl (CNA #1) does not know what she is doing. Nurse #2 said she and Nurse #1 assessed Resident #1 and he/she yelled it hurts when he/she moved his/her left leg. Nurse #2 said Resident #1 was transported to the Hospital Emergency Department for evaluation. Review of CNA #1's Written Witness Statement, dated 09/30/22, indicated that she transferred Resident #1 out of bed with the sit-to-stand mechanical lift. The Statement indicated that she (CNA #1) turned the mechanical lift, Resident #1 became unsteady, and the mechanical lift tipped over sideways, and Resident #1 fell . The Statement indicated that she (CNA #1) could not stop he/she from falling. During an interview on 10/26/22 at 1:23 P.M., Certified Nurse Aide #1 said that she transferred Resident #1 with the sit-to-stand mechanical lift and then went to turn the lift, Resident #1 became unsteady, the mechanical lift tipped over and Resident #1 fell on the floor with the mechanical lift landing on top of him/her. CNA #1 said that she unhooked Resident #1 from the mechanical lift, picked the mechanical lift up and moved it away from him/her. CNA #1 said that she transferred Resident #1 with the sit-to-stand mechanical lift alone, without the assistance of another staff member present to help. CNA #1 said she was aware that Resident #1 required two staff members to be present and assist with sit-to-stand mechanical lift transfers. Review of a Hospital Emergency Department Report, dated 09/30/22, indicated that Resident #1 was seen in the Emergency Department for left ankle pain after injury. The Report indicated that an X-ray revealed Resident #1 had a fracture of left distal tibia and fibula (ankle) and indicated that his/her left ankle was placed in an ortho glass splint (soft cast) and to follow up with an orthopedic physician. During an interview on 10/25/22 at 2:47 P.M., the Director of Nurses (DON) said CNA #1 told her that she used the sit-to-stand mechanical lift by herself to transfer Resident #1 and that he/she became unsteady and fell on the floor. The DON said CNA #1 acknowledged that she was aware that two staff members were required to participate during all mechanical lift transfers.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose plan of care indicated he/she required two staff members to assist with bed mobility including repositioning, the Facility failed to ensure staff implemented and followed interventions from the plan of care, when on 11/10/20, Certified Nurse Aide (CNA #1) repositioned Resident #1 in bed while trying to remove a mechanical lift pad out from underneath him/her, without the assistance of another staff member, Resident #1's legs slid off the bed, he/she fell on to the floor, sustained right [MEDICAL CONDITION] and required hospitalization . Findings include: Review of The Facility's Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised November 2017, indicated that the Comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition changes. Review of the Facility's Policy titled Safety and Supervision of Residents, dated as revised April 2018, indicated that staff shall implement interventions to reduce accident risk and hazards by: -Ensuring that the interventions are implemented; and -Interventions are implemented correctly and consistently. Resident #1 was admitted to the Facility in May 2014, [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she required an extensive assist of two staff members for bed mobility, including repositioning. Review of Resident #1's Plan of Care related to Activities of Daily Living, dated as reviewed 10/28/2020, indicated Resident #1 required the assistance of two staff members with positioning and bed mobility. Review of the Facility's Investigation, dated 11/10/20, indicated the Resident #1 was transferred back to bed by CNA #1 and CNA #2, via the mechanical lift. The Investigation indicated Resident #1 was in bed on his/her side as CNA #1 (without another staff member present) removed the mechanical lift pad out from underneath Resident #1, and he/she fell out of bed. During an interview on 1/12/2021 at 11:49 A.M., Certified Nurse Aide (CNA) #1 said that Resident #1 was always transferred by two staff members while using a mechanical lift. CNA #1 said Resident #1 tended to become anxious, which can impact his/her required level of assistance for bed mobility and that is why two staff members are needed to assist him/her. CNA #1 said she was attempting to remove the mechanical lift pad when Resident #1 legs slide off the bed. During an interview on 1/12/2021 at 12:17 P.M., Nurse #1 said CNA #1 told him that at the time of the incident, CNA #2 was taking the mechanical lift out of the room to put it in the hallway to get it out of the way, and that she (CNA #1) then tried to reposition Resident #1 to remove the mechanical lift pad out from underneath his/her. During an interview on 1/13/2021 at 3:30 P.M., Certified Nursing Aide (CNA) #2 said that Resident #1 was always transferred by a mechanical lift. CNA #2 said that Resident #1 required two staff members to assist him/her with all activities of daily living (ADL) care, including repositioning. During an interview on 1/12/2021 at 2:09 P.M., the Staff Development Coordinator (SDC) said all staff had to complete annual competencies regarding the use of a mechanical lift which included watching a video demonstration of proper transfer and ergonomics, and had to complete a quiz. The SDC said the staff member working the mechanical lift would typically remove the lift from the room to get it out of the way, that staff member would return to the room, and then the two staff members would work together to remove the lift pad from underneath the resident. During an interview on 1/12/2021 at 2:09 P.M., the Certified Occupational Assistant (COTA) said two staff members are required when transferring a resident in/out of bed with a mechanical lift, and that once the resident is back in bed, the two staff members would work together to remove the lift pad out from underneath the resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required the assistance of two staff members with bed mobility including repositioning, the Facility failed to ensure that Resident #1's safety was maintained to prevent an incident/accident with injury, when on 11/10/20, Certified Nurse Aide (CNA #1) repositioned Resident #1 in bed in an attempt to remove the mechanical lift pad out from underneath him/her, without the assistance of another staff member, Resident #1's legs slid off the bed, he/she fell on to the floor, complained of pain, was transferred to the Hospital Emergency Department for evaluation, was diagnosed with [REDACTED]. Findings include: Review of the Facility's Policy titled Safety and Supervision of Residents, dated as revised April 2018, indicated that staff shall implement interventions to reduce accident risk and hazards by: -Communicating specific interventions to all relevant staff; -Assigning responsibility for carrying out interventions; -Providing training as necessary; -Ensuring that the interventions are implemented; and -Documenting and monitoring interventions -Interventions are implemented correctly and consistently Review of the Facility's Investigation, dated 11/10/20, indicated the Certified Nurse Aide (CNA) #1 said that Resident #1 was in bed, positioned on his/her side so she (CNA #1) could remove the mechanical lift pad out from underneath him/her. The Investigation indicated Resident #1 began shaking on and banging on the side rail, when CNA #1 noticed that Resident #1 legs stiffened, and began sliding off the bed. The Investigation indicated CNA #1 attempted to keep Resident #1 legs from sliding of the bed, but she was unable to prevent Resident #1 from falling off the bed and onto the floor. The Investigation indicated Resident #1 was admitted to the hospital, where he/she received treatment for [REDACTED]. Resident #1 was admitted to the Facility in May 2014, [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that he/she required an extensive assist of two staff members for bed mobility, including repositioning, and transfers. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 11/10/20, indicated that CNA #2 helped her (CNA #1) transfer Resident #1 into bed from his/her wheelchair using a mechanical lift. The Statement indicated that CNA #2 took the mechanical lift out of the room. The Statement indicated that Resident #1 fell on to the floor when she (CNA #1, without the assistance of another staff member) repositioned Resident #1 and pulled the mechanical lift pad out from underneath Resident #1. During an interview on 1/12/2021 at 12:17 P.M., Nurse #1 said he was called to Resident #1's room for help and observed Resident #1 lying on the floor near his/her bed, and said Resident #1 appeared to be in a kneeling position. Nurse #1 said CNA #1 told him that at the time of the incident, CNA #2 was taking the mechanical lift out of the room to put it in the hallway, and that she (CNA #1) then tried to reposition Resident #1 to remove the mechanical lift pad out from underneath his/her. During an interview on 1/12/2021 at 2:09 P.M., the Staff Development Coordinator (SDC) said all staff had to complete annual competencies regarding the use of a mechanical lift which included watching a video demonstration of proper transfer and ergonomics, and had to complete a quiz. The SDC said the staff member working the mechanical lift would typically remove the lift from the room to get it out of the way, that staff member would return to the room, and then the two staff members would work together to remove the lift pad from underneath the resident. During an interview on 1/12/2021 at 2:09 P.M., the Certified Occupational Assistant (COTA) said two staff members are required when transferring a resident in/out of bed with a mechanical lift, and that once the resident is back in bed, the two staff members would work together to remove the lift pad out from underneath the resident. During an interview on 1/12/21 at 1:36 P.M., CNA #3 said two staff members are needed to use a mechanical lift, and to remove a mechanical lift pad out from underneath a resident. During an interview on 1/12/21 at 1:49 P.M., CNA #4 said two staff members are required to remove a mechanical lift pad out from underneath a resident.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required assistance of two staff members with transfers, the Facility failed to ensure staff maintained his/her safety to prevent any injury or accident during a transfer and failed to ensure Resident #1 was provided with adequate assistance during a transfer, when Resident #1 was transferred by Certified Nurse Aide (CNA) #1, unassisted by another staff member, and sustained a laceration to his/her right lower extremity that required eight sutures to close. Findings include: The Policy titled, Comprehensive Person-Centered Care Plans, dated as revised in (MONTH) (YEAR), indicated that the Interdisciplinary Team develops a comprehensive, person-centered care plan for each resident to meet the resident's physical, psychosocial and functional needs. The Policy indicated care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and aid in preventing or reducing decline in the resident's functional status. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) Assessment, dated 6/6/18, indicated Resident #1 was severely cognitively impaired, was totally dependent and required assistance of two staff members for transfers. Resident #1's plan of care for Activities of Daily Living (ADL), dated 6/14/18, indicated he/she had self-care performance deficits and required assistance of two staff members for transfers. Resident #1's Profile Care Card, dated 7/2018, indicated he/she was dependent and required assistance of two staff members with transfers. A Resident Event Report, dated 7/2/18 at 4:30 P.M., indicated Resident #1 sustained a laceration to his/her right lower leg while being transferred by CNA #1. A Nursing Home to Hospital Transfer Form, dated 7/2/18, indicated that at 4:30 P.M. Resident #1 was being transferred from bed to wheelchair by a CNA, sustained a five centimeter long laceration to his/her right leg and was transferred to the hospital. The physician's orders [REDACTED].#1 to the hospital for evaluation and treatment related to a laceration on the right lower extremity. The Health Care Facility Reporting System (HCFRS) Report, dated 7/6/18, indicated that on 7/2/18 at 4:30 P.M., Resident #1 was being transferred from the bed to wheelchair by CNA #1, when blood was noted dripping on the floor from Resident #1's right lower leg. The Report indicated Resident #1 was transferred with assistance of only one staff member, that Resident #1 required assistance of two staff members for transfers, and that Resident #1's plan of care was not followed. The Report indicated Resident #1 sustained a five centimeter long laceration to his/her right lower extremity and was transferred to the hospital where he/she required eight sutures to close the wound. CNA #1's written witness statement, dated 7/2/18, indicated she (CNA #1) transferred Resident #1 from the bed to the wheelchair, noticed blood dripping onto the floor from Resident #1's leg and that Resident #1 had a cut on his/her leg. A Nurse Progress Note, dated 7/2/18, indicated Resident #1 was found in his/her wheelchair bleeding from a cut on his/her right leg and was transferred to the hospital. A Hospital Discharge Summary Report, dated 7/2/18, indicated Resident #1 required eight sutures to close the laceration to his/her right lower extremity. The Surveyor interviewed Nurse #1 at 1:37 P.M. on 10/24/18. Nurse #1 said Resident #1 required assistance of two staff members with transfers and said CNA #1 transferred Resident #1 without assist. Nurse #1 said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Unit Manager at 2:52 P.M. on 10/24/18. The Unit Manager said CNA #1 knew Resident #1 required assistance of two staff members with transfers and said that CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Director of Nurses (DON) at 3:30 P.M. on 10/24/18. The DON said CNA #1 knew Resident #1 required assistance of two staff members with transfers and that CNA #1 transferred Resident #1 without assist of another staff member. The DON said that CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed CNA #1 at 11:14 A.M. on 10/25/18. CNA #1 said she was an agency CNA and said she had only worked in the facility two times, including the day of the incident. CNA #1 said no one from the Facility showed her Resident #1's plan of care for transfers, and said that no one told her about Resident #1's Profile Care Card. CNA #1 said that Facility staff did not tell her much about her assignment at all. CNA #1 said she wasn't sure if Resident #1 required one or two staff members with transfers and said she transferred Resident #1 without an assist. CNA #1 said that after she transferred Resident #1, she noticed blood dripping from Resident #1's leg but could not recall if Resident #1 bumped into anything during the transfer.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure staff followed Resident #1's plan of care related to transfers, when Resident #1, who required the assistance of two staff members with all transfers, was transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #1, without another staff member, resulting in Resident #1 sustaining a laceration to his/her right lower extremity, which required eight sutures to close. Findings include: The Policy titled, Comprehensive Person-Centered Care Plans, dated as revised in (MONTH) (YEAR), indicated that the Interdisciplinary Team develops a comprehensive, person-centered care plan for each resident to meet the resident's physical, psychosocial and functional needs. The Policy indicated care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and aid in preventing or reducing decline in the resident's functional status. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) Assessment, dated 6/6/18, indicated Resident #1 was severely cognitively impaired, was totally dependent and required assistance of two staff members for transfers. Resident #1's plan of care for Activities of Daily Living (ADL), dated 6/14/18, indicated he/she had self-care performance deficits and required assistance of two staff members for transfers. Resident #1's Profile Care Card, dated 7/2018, indicated he/she was dependent and required assistance of two staff members with transfers. A Resident Event Report, dated 7/2/18 at 4:30 P.M., indicated Resident #1 sustained a laceration to his/her right lower leg while being transferred by CNA #1. A Nursing Home to Hospital Transfer Form, dated 7/2/18, indicated that at 4:30 P.M. Resident #1 was being transferred from bed to wheelchair by a CNA, sustained a five centimeter long laceration to his/her right leg and was transferred to the hospital. The physician's orders [REDACTED].#1 to the hospital for evaluation and treatment related to a laceration on the right lower extremity. The Health Care Facility Reporting System (HCFRS) Report, dated 7/6/18, indicated that on 7/2/18 at 4:30 P.M., Resident #1 was being transferred from the bed to wheelchair by CNA #1, when blood was noted dripping on the floor from Resident #1's right lower leg. The Report indicated Resident #1 was transferred with assistance of only one staff member, that Resident #1 required assistance of two staff members for transfers, and that Resident #1's plan of care was not followed. The Report indicated Resident #1 sustained a five centimeter long laceration to his/her right lower extremity and was transferred to the hospital where he/she required eight sutures to close the wound. CNA #1's written witness statement, dated 7/2/18, indicated she (CNA #1) transferred Resident #1 from the bed to the wheelchair, noticed blood dripping onto the floor from Resident #1's leg and that Resident #1 had a cut on his/her leg. A Nurse Progress Note, dated 7/2/18, indicated Resident #1 was found in his/her wheelchair bleeding from a cut on his/her right leg and was transferred to the hospital. A Hospital Discharge Summary Report, dated 7/2/18, indicated Resident #1 required eight sutures to close the laceration to his/her right lower extremity. The Surveyor interviewed Nurse #1 at 1:37 P.M. on 10/24/18. Nurse #1 said Resident #1 required assistance of two staff members with transfers and said CNA #1 transferred Resident #1 without assistance from another staff member. Nurse #1 said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Unit Manager at 2:52 P.M. on 10/24/18. The Unit Manager said CNA #1 knew Resident #1 required assistance of two staff members with transfers and said that CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Director of Nurses (DON) at 3:30 P.M. on 10/24/18. The DON said CNA #1 knew Resident #1 required assistance of two staff members with transfers and that CNA #1 transferred Resident #1 without assistance from another staff member. The DON said that CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed CNA #1 at 11:14 A.M. on 10/25/18. CNA #1 said she was an agency CNA and said she had only worked in the facility two times, including the day of the incident. CNA #1 said no one from the Facility showed her Resident #1's plan of care for transfers, and said that no one told her about Resident #1's Profile Care Card. CNA #1 said that Facility staff did not tell her much about her assignment at all. CNA #1 said she wasn't sure if Resident #1 required one or two staff members with transfers and said she transferred Resident #1 without an assist.