Every finding on record at Fall River Jewish Home

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one Resident (#12), out of a total sample of 18 residents. Specifically, the facility failed to develop a comprehensive person center care plan for Resident #12's implanted venous access device.Findings include: Review of the facility policy titled Care Plans-Comprehensive, revised July 2023, indicated but was not limited to:-An individualized, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident.-Our facility's Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may expect to attain.-The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.-Each resident 's comprehensive care plan is designed to: Incorporate identified problem areas and incorporate risk factors associated with identified problems.Resident #12 was admitted to the facility in October 2025 with diagnoses including malignant neoplasm of the tongue (tongue cancer) and implanted port-a-cath (implanted port, medical device placed completely under the skin, usually in the upper chest).Review of the Minimum Data Set (MDS) assessment, dated 7/8/26, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.Review of Resident #12's Palliative Care note, dated 7/14/26, indicated but was not limited to: -3/28/25-4/2/25: admitted with failure to thrive and difficulty swallowing- port-a-cath placement due to high risk for complications. -Skin: port-a-cath.Review of Resident #12's Oncology Report Note, dated 7/21/26, indicated but was not limited to: -Recommendations: Return in three months for laboratory visit and port flushes.Review of the Comprehensive Care Plan failed to indicate a care plan for Resident #12's port-a-cath had been developed.During an interview on 8/4/26 at 4:20 P.M., the Director of Nursing said her and the MDS Nurse were responsible for developing comprehensive care plans. She said Resident #12 did not have a care plan developed for his/her port-a-cath but should have had one developed.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of two nurses observed during a medication pass made three errors out of 27 opportunities, resulting in a medication error rate of 11.11%. Those errors impacted three Residents (#6, #27, and #60), out of nine residents observed. Specifically:1. For Resident #6, an incorrect dose of Cholecalciferol (Vitamin D3, a fat-soluble vitamin used to treat or prevent vitamin D deficiency, support bone strength with calcium, and maintain immune and muscle health) was administered;2.For Resident #60, an incorrect formula of a probiotic (live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the gut) was administered; and,3. For Resident #27, an incorrect formula of a vitamin was administered.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to:- Medications shall be administered in a safe and timely manner, and as prescribed.- Medications must be administered in accordance with the orders.-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1.On 8/4/26 at 8:40 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #6 including:-Cholecalciferol 25 micrograms (mcg) (1000 units) one tablet Review of Resident #6's Physician's Orders indicated but not limited to:- Cholecalciferol 25 mcg (1000 units) give two tablets by mouth one time a day (for a total dose of 2000 units), dated 7/1/26 During an interview on 8/4/26 at 12:29 P.M., Nurse #2 and the surveyor reviewed Resident #6's order for Cholecalciferol. Nurse #2 said Resident #6 had an order for Cholecalciferol 25 mcg (1000 units) give two tablets by mouth one time a day, Nurse #2 said he only administered one tablet of Cholecalciferol 25 mcg (1000 units) instead of the prescribed two tablets as ordered by the physician. 2. On 8/4/26 at 9:13 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #60 including:-Saccharomyces boulardii (a yeast-based probiotic) one capsule Review of Resident #60's Physician's Orders indicated but was not limited to:-Acidophilus (bacteria based probiotic) give one capsule one time daily, dated 1/15/26 During an interview on 8/4/26 at 11:54 A.M., Nurse #1 and the surveyor reviewed Resident #60's order for Acidophilus. Nurse #1 showed the surveyor a medication bottle of Saccharomyces boulardii and said it is the house probiotic, and the facility did not have any Acidophilus. She said she administered Saccharomyces boulardii to Resident #60 with his/her morning medications instead of Acidophilus. During an interview on 8/4/26 at 12:44 P.M., Consulting Pharmacist #1 said Acidophilus and Saccharomyces boulardii were both probiotics. He said Acidophilus was a bacteria based probiotic while Saccharomyces boulardii was a yeast based probiotic. He said while both Acidophilus and Saccharomyces boulardii are both probiotics they work differently. 3. On 8/4/26 at 9:24 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #27 including:-Multivitamin with Minerals (a daily supplement containing a blend of essential vitamins (like A, C, D, E, K, and B-complex) and dietary minerals (like calcium, magnesium, zinc, and iron) two tablets. Review of Resident #27's Physician's Orders indicated but was not limited to:-Ocuvite-Lutein (an eye vitamin and mineral supplement containing 2 milligrams (mg) of lutein along with essential antioxidants like vitamins A, C, and E, plus zinc, copper, and selenium to support macular health) give two tablets one time a day. During an interview on 8/4/26 at 12:26 P.M., Nurse #2 reviewed Resident #27's Ocuvite-Lutein order. Nurse #2 held up a bottle of Multivitamin with Mineral and said during the morning medication pass he administered a Multivitamin with Minerals to Resident #27 instead Ocuvite-Lutein as ordered by the physician. During an interview on 8/4/26 at 12:44 P.M., Consulting Pharmacist #1 said Ocuvite-Lutein and a Multivitamin with Minerals are both vitamins, but they are two different medications containing different minerals. He said a Multivitamin with Minerals does not contain lutein and copper and has a larger amount of minerals and vitamins. He said Ocuvite-Lutein is for eye health while a Multivitamin with Minerals is not. During an interview on 8/4/26 at 2:25 P.M., the Director of Nursing said nurses must administer medications per physician orders. She said if a certain medication is not in the facility then the physician must be called to see if a house stock medication can be used or the prescribed medication needed to be ordered.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medication and treatment carts were locked and secured when not in direct supervision of a licensed nurse on two of two units.Findings include:Review of the facility policy titled Storage of Medications, last revised July 2025, indicated but was not limited to:-The facility stores all drugs and biologicals in a safe secure, and orderly manner.-Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications.-Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologics are locked when not in use. Unlocked medication carts are not left unattended. On 8/4/26, the surveyor observed the following on Unit Two:-At 8:04 A.M., the treatment cart in the hallway was unlocked and unattended.-At 8:05 A.M., the Assistant Director of Nursing walked by the unlocked/unattended treatment cart and went down the hallway, out of sight of the treatment cart.-At 8:08 A.M., the Food Service Director, Administrator, and the Activity Director walked by the unlocked/unattended treatment cart.-At 8:09 A.M., the Administrator and the Activity Director walked by the unlocked/unattended treatment cart.- At 8:09 A.M., the Administrator walked by the unlocked/unattended treatment cart.-At 8:11 A.M., a Certified Nursing Assistant walked by the unlocked/unattended treatment cart.-At 8:12 A.M., the Assistant Director of Nursing walked by the unlocked/unattended treatment cart and went down the hallway, out of sight of the treatment cart.-At 8:13 A.M., the Administrator and the Activity Director walked by the unlocked/unattended treatment cart.-At 8:24 A.M., two Certified Nursing Assistants walked by the unlocked/unattended treatment cart.-At 8:25 A.M., the Activity Director walked by the unlocked/unattended treatment cart.-At 8:28 A.M., the Director of Social Services walked by the unlocked/unattended treatment cart.-At 8:32 A.M., the Director of Nursing and a Certified Nursing Assistant walked by the unlocked/unattended treatment cart.-At 2:42 P.M., the treatment cart in the hallway was unlocked and unattended.-At 2:50 P.M., Nurse #1 and Nurse #2 walked by the unlocked/unattended treatment cart and went down the hallway, out of sight of the treatment cart. A Certified Nursing Assistant walked by the unlocked/unattended treatment cart.-At 2:52 P.M., a Resident walked by the unlocked/unattended treatment cart. On 8/4/2026 the surveyor observed the following on Unit Three:-At 11:35 A.M., the treatment cart in the hallway was unlocked and unattended.-At 11:51 A.M., the treatment cart in the hallway was unlocked and unattended. There was one resident seated in his/her wheelchair across from the Nursing Station and diagonally across from the unlocked/attended treatment cart. A visitor and a staff member walked past the unlocked/attended treatment cart. On 8/5/2026 the surveyor observed the following on Unit Two:-12:47 P.M., the medication cart was unlocked and unattended inside the nursing station. The door to the Nursing Station open and unattended. During an interview on 8/5/26 at 12:53 P.M., Nurse #3 said the door to the nursing station should have been closed and locked if unattended. She said the medication cart and the treatment carts should not be left unlocked and unattended if not in direct view/supervision of a nurse. She said the medication cart should not have been left unlocked and unsecured in the nursing station with the door to the nursing station unlocked and opened. During an interview on 8/5/26 at 1:05 P.M., Nurse #1 said treatment carts should always be locked and secured when not in direct view of a nurse because they have resident specific prescriptions and treatment supplies in them and no one, but the nursing staff should have access to them. During an interview on 8/5/26 at 1:07 P.M., the Director of Nursing said medication and treatment carts must be stored in safe and secure manner and the nursing station door should be closed and secured if an unlocked medication cart is being stored in it.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for two Residents (#12 and #166), out of a total of 2 residents receiving intravenous therapy. Specifically, the facility failed to change the PICC dressing per professional standards. Findings include: Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, undated, indicated but was not limited to the following: - The purpose of the procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or well dressings. - Maintain sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) dressing for all central vascular access devices. - Change the dressing if it becomes damp, loosened or visibly soiled and: - at least every 7 days for TSM dressing; - at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured. Review of the Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections, last revised October 2017, indicated but was not limited to: - Catheter Site Dressing Regimens: - Replace dressings used on short-term CVC (central vascular catheter) sites every 2 days for gauze dressings. - Replace dressings used on short-term CVC sites at least every 7 days for transparent Dressings. (https://www.cdc.gov/infection-control/media/pdfs/Guideline-BSI-H.pdf) Review of the National Library of Medicine (NLM), dated 5/15/23, indicated but was not limited to: - Gauze (a fabric dressing that does not stick to the skin) dressings to be changed every 48 hours, and transparent semi permeable dressings every seven days. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8765739/) 1. Resident #12 was admitted to the facility in May 2025 with diagnoses including staphylococcal arthritis (serious joint infection that can lead to significant damage if not treated promptly). Review of the Minimum Data Set (MDS) assessment, dated 5/21/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated Resident #12 had a central line and received intravenous (IV) antibiotic medication. Review of Resident #12's current Physician Orders indicated but was not limited to: - Change transparent dressing to PICC every 7 days and as needed, dated 6/8/2025 - Change transparent dressing to PICC every 7 days, dated 6/8/2025, discontinued 6/8/25 During an interview 6/10/25 at 8:37 A.M., the surveyor observed Resident #12 in bed with a PICC line in his/her right upper arm. There was a 2 centimeter (cm) x 2 cm split gauze over the insertion point of the PICC line covered with transparent dressing, dated 6/4/25. Resident #12 said he/she had received IV antibiotics through his/her PICC line. During an interview on 6/10/25 at 10:36 A.M., Nurse #2 said when he would change a PICC line dressing prior to applying the transparent dressing he would first cover the PICC line at the insertion point with gauze. Nurse #2 observed Resident #12's PICC line dressing and said he had changed the dressing on 6/4/25 and prior to applying the transparent dressing he had covered the PICC line with gauze at the insertion point. Nurse #2 said PICC line dressings were changed every seven days and as needed. Nurse #2 said he followed the facility policy for PICC line dressings. 2. Resident #166 was admitted to the facility in May 2025 with diagnoses of cellulitis (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue). Review of the MDS assessment, dated 6/5/25, indicated Resident #166 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS assessment indicated Resident #166 had a central line and received IV antibiotic medication. Review of Resident #166's current Physician's Orders indicated but was not limited to: - Change transparent dressing to PICC one time only for IV maintenance for 1 Day 24 hours post insertion or on admission AND every day shift every 7 days AND as needed, dated 5/29/2025 On the following days and times, the surveyor observed Resident #166 in bed with a PICC line in his/her right upper arm. There was a 2 cm x 2 cm gauze over the insertion point of the PICC line covered with a transparent dressing, dated 6/5/25: - 6/8/25 at 9:07 A.M., - 6/9/25 at 8:35 A.M., and - 6/10/25 at 8:33 A.M. During an interview on 6/8/25 at 9:07 A.M., Resident #166 said he/she had received two different antibiotics through his/her PICC line. Resident #166 said the last time his/her dressing was changed was on 6/5/25. During an interview on 6/10/25 at 10:36 A.M., Nurse #2 said when he would change a PICC line dressing prior to applying the transparent dressing he would first cover the PICC line at the insertion point with gauze. Nurse #2 observed Resident #166's PICC line dressing and said he had changed the dressing on 6/5/25 and prior to applying the transparent dressing he had covered the PICC line with gauze at the insertion point. Nurse #2 said PICC line dressings were changed every seven days and as needed. Nurse #2 said he followed the facility policy for PICC line dressings. During an interview on 6/10/25 at 11:00 A.M., the Regional Clinical Coordinator observed the PICC line dressings for Residents #12 and #166 and said both PICC lines were covered with gauze and transparent dressing. The Regional Clinical Coordinator said PICC line dressings were changed every seven days and as needed, according to facility policy. The Regional Clinical Coordinator reviewed the facility policy and the dressings for Resident #12 and Resident #166 and said the gauze dressings should have been changed every two days per facility policy and infection control purposes.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities and failed to maintain a QAPI program which addressed the full range of care and services including clinical care. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, last reviewed 2/28/23 indicated the following: -QAPI plan addresses: -clinical care including quality measures, falls, medication errors, pressure ulcers, incident reports, infection control and quality of life including concerns brought up through resident council -the Administrator is responsible and accountable for developing, leading and closely monitoring a QAPI program -the QAPI Committee meets monthly and maintains minutes of all activity -the Committee maintains a QAPI manual that houses meeting minutes, project [NAME], performance improvement projects (PIP), data, data analysis and sample performance improvement support tools -the information gathered is analyzed and compared to benchmarks and/or targets established by the facility -QAPI teams analyze data regularly as part of their project assignments -PIP projects are developed based on a prioritizing process with a minimum of one project at a time -the QAPI Committee makes plans describing what areas of the process we are going to change (where breakdowns were observed), utilizing the Performance Improvement Plan and Monitoring Tool; using a structured Root Cause Analysis and Plan-Do-Study-Act depending on the issue/opportunity -the QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements -if changes to the process have not resulted in the goal of the PIP, further changes are made and monitoring of the process takes place again During an interview on 6/10/25 at 2:00 P.M., the Administrator said the QAPI Committee met monthly to discuss any major issues and projects that were being worked on. Review of the QAPI manual included the following monthly minutes: January 2025: -pharmacy consultant reviewed new regulatory requirement, -laboratory vendor change in February 2025, -update to the Facility Assessment, -awaiting the next 5-star report for measurable results -sent Survey Readiness Folder including pathways to departments for self-assessment and development of QAPI projects based upon their findings February 2025: no meeting minutes included March 2025: no meeting minutes included April 2025: no meeting minutes included May 2025: no meeting minutes included During an interview on 6/10/25 at 2:00 P.M., the Administrator said he started working at the facility at the end of January 2025 and facilitated the QAPI Committee meetings since February 2025. He said the QAPI Committee meets monthly and has discussions. He said there were no meeting minutes for the monthly meetings from February through May 2025. He said the departments work on different things and there were no projects until March 2025 when the facility initiated a QAPI project for concerns with food temperature. He said that he had never heard that there had always needed to be a project. Review of QAPI manual for February 2025 included the following: -a sheet titled Nursing Report for QA, dated February 2025 listed the following identified areas of potential concern: falls, call light response time, reportable events, antibiotics, bruises and weights; under the section labeled Current PIPs it listed None. -a sheet titled Department: Maintenance: which listed things that were worked on during the month (replaced kitchen light bulbs, dryer repair came in, extinguishers checked, etc.) -a sheet titled Activity Department: which indicated the amount of residents seen for bedside visits and what activity was provided (picture book, hand massages, etc.) -a sheet titled Therapy QAPI which listed the percentage of residents seen per payer source Review of the QAPI manual for March 2025 included the same lists from February without any indication of corrective actions or monitoring with one additional department sheet: Dietary: Food temperatures: plan weekly audits to be completed until compliant. Review of the QAPI manual for April 2025 included the same lists from March 2025 without any indication of corrective actions or monitoring including: Dietary: no information provided regarding how the food temperature audits were going and what corrective actions were identified Nursing: added a PIP of provider notes to be added to the electronic medical record, with no indication of corrective actions or what monitoring would be conducted Review of the QAPI manual for May 2025 included the same lists from April 2025 without any indication of corrective actions or monitoring including but not limited to: Dietary: new food truck arrived, no additional information was provided regarding the monitoring of the corrective action Nursing: provider notes to be added to electronic medical record with no indication of the corrective action being implemented or the status of the project During an interview on 6/10/25 at 2:00 P.M., the Administrator said the QAPI Committee met and held discussions about how the potential areas were going, but no data could be provided, adding we worked on these areas, we don't necessarily write down the information of goals or data.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to develop and implement appropriate plans of action for resident concerns regarding food temperatures. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, last reviewed 2/28/23, indicated the following: -QAPI plan addresses: -clinical care including quality measures, falls, medication errors, pressure ulcers, incident reports, infection control and quality of life including concerns brought up through resident council -the Administrator is responsible and accountable for developing, leading and closely monitoring a QAPI program -the QAPI Committee meets monthly and maintains minutes of all activity -the Committee maintains a QAPI manual that houses meeting minutes, project [NAME], performance improvement projects (PIP), data, data analysis and sample performance improvement support tools -the information gathered is analyzed and compared to benchmarks and/or targets established by the facility -QAPI teams analyze data regularly as part of their project assignments -PIP projects are developed based on a prioritizing process with a minimum of one project at a time -the QAPI Committee makes plans describing what areas of the process we are going to change (where breakdowns were observed), utilizing the Performance Improvement Plan and Monitoring Tool; using a structured Root Cause Analysis and Plan-Do-Study-Act depending on the issue/opportunity -the QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements -if changes to the process have not resulted in the goal of the PIP, further changes are made and monitoring of the process takes place again During an interview on 6/10/25 at 2:00 P.M., the Administrator said he started working at the facility at the end of January 2025 and facilitated the QAPI Committee meetings since February 2025. He said the QAPI Committee meets monthly and has discussions. He said there were no meeting minutes for the monthly meetings from February through May 2025. He said the departments work on different things and there were no projects until March 2025 when the facility initiated a QAPI project for concerns with food temperature. Review of the QAPI manual for March 2025 included the following on a typed up page: Dietary: Food temperatures self-identified; weekly audits three times per week for one month then two times a week for 60 days, if audits are 100%; if the issue continues audits will continue until food temperatures are compliant with state regulations Review of Food Committee Minutes indicated the following resident concerns: -1/6/25: Food cold when arrives to resident rooms; The kitchen is trying to keep the food hotter. Food Service Director (FSD) is looking into new food trucks. -3/6/25: In process of ordering new food delivery carts. -4/28/25: In process of ordering new food delivery carts. -5/8/25: The residents say their food is cold when they get it in their rooms; The FSD is still trying to get new food trucks so it will keep the food hotter; four residents in attendance let the FSD know the breakfast and lunch food was hotter. Review of the QAPI manual for April 2025 included the same typed up page from March 2025, now dated April 2025. The page failed to indicate how the food temperature audits were going and what corrective actions were identified. Review of the QAPI manual for May 2025 included the same lists from April 2025 without any indication of corrective actions or monitoring including but not limited to: Dietary: new food truck arrived, no additional information was provided regarding the monitoring of the corrective action On 6/8/25 at 7:54 A.M., the surveyor observed one meal truck that enclosed trays within it and two pushcarts with no walls or doors to enclose the breakfast trays. The last breakfast tray from the push cart was delivered at 8:40 A.M. On 6/9/25 at 10:30 A.M., at the Resident Group the residents said food temperatures were improving but were still not good. On 6/10/25 at 8:05 A.M., the surveyor observed the breakfast tray line with the FSD. The kitchen staff were observed by the surveyor and the FSD to place breakfast trays on the open push carts. During an interview on 6/10/25 at 2:00 P.M., the Administrator said the FSD was conducting test tray audits and he had the audits available for review. He said in terms of corrective action the facility had purchased a new food truck for meal delivery, but he was unaware that some of the meals had continued to be served from open push carts and the FSD had not mentioned this as part of the QAPI. He said there was no documentation to indicate the goal of how many test trays should be within temperature range or any documentation to evaluate the effectiveness of the corrective action of ordering a new food truck.

Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement control measures for Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens that could grow and spread in the facility's water system. Findings include: Review of Centers for Medicare & Medicaid Services (CMS) Memorandum titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease, revised July 2018, indicated but was not limited to the following: - In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least [AGE] years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Examples of these system components and devices include: - Hot and cold-water storage tanks - Water heaters - Water-hammer arrestors - Pipes, valves, and fittings - Expansion tanks - Water filters - Electronic and manual faucets - Aerators - Faucet flow restrictors - Showerheads and hoses - Centrally-installed misters, atomizers, air washers, and humidifiers - Non-steam aerosol-generating humidifiers - Eyewash stations - Ice machines - Hot tubs/saunas - Decorative fountains - Cooling towers - Medical devices (such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units) CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, non-tuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Review of the facility's policy titled Water Management Program to Reduce Growth and Spread, last reviewed March 24, 2025, indicated but was not limited: - Policy: It is the policy of the facility to reduce the risk of the growth and spread of Legionella. - Procedure: The facility will identify and manage hazardous conditions that support growth and the spread of Legionella. - The facility must conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system and assess how much risk hazardous conditions in those water system pose. - Based on the risk assessment, implement a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens. - Specify testing controls and acceptable ranges for control measures and document results of testing and corrective actions when control limits are not maintained. - Control measures to reduce the hazardous conditions whenever possible to prevent Legionella growth and spread. - Review the elements of the water management program at least once a year to make sure the program is running as designed and is effective. Review of the Water Management Program indicated but was not limited to: - Policy and Procedure Acknowledgement, dated 3/19/25 During an interview on 6/10/25 at 11:44 A.M., the Regional Director of Maintenance said last year the facility implemented as part of the control measures to prevent Legionella growth, the facility would flush the water system quarterly. He said he could not provide evidence of the flushing or say when it was last done. The Director of Maintenance provided the surveyor with a schematic of the facility and a diagram of control measures and corrective actions. The schematic and diagram did not refer to a flushing schedule. During an interview on 6/10/25 at 11:39 A.M., the Director of Maintenance said he had been working at the facility for six months and had not flushed the water system. The facility failed to provide documentation of water flushing.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#56), out of a total sample of 16 residents, was assessed by the Interdisciplinary Care Team for self-administration of all their medications and had a physician's order to self-administer medications. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled Safety and Supervision of Residents, last revised April 2018, indicated but was not limited to: - Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. - As part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - The staff and/or practitioner will document their findings and the choices of residents who are able to self-administer medications. - Self-administered medications must be stored in a safe and secure place which is not accessible by other residents. - The staff and practitioner will periodically (for example, during quarterly MDS reviews) re-evaluate a resident's ability to continue to self-administer medications. Resident #56 was admitted to the facility in March 2025 with diagnoses including myocardial infarction (heart attack) and tachycardia (a heart rate faster than 100 beats per minute at rest). Review of the Minimum Data Set (MDS) assessment, dated 5/28/25, indicated Resident #56 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated the Resident was able to perform activities of daily living with supervision. During an interview with observation on 6/8/25 at 8:22 A.M., the surveyor observed Resident #56 sitting on the edge of his/her bed with the following: - A napkin on his/her bed which contained: - One white capsule broke in half, - One yellow oval pill, - One red and white oval capsule, - One round pink tablet, - One yellow round tablet, - Three small oval white tablets, - Three medium sized round tablets, - Two large round tablets, and - One small round tablet. - Three medication cups on his/her overbed table which contained: - One with one round white medium sized tablet, - One with four round white medium sized tablets, and - One with one yellow oval pill and one red oval capsule. - A plastic cup containing two 2 milliliter (ml) nebulizer vials on his/her nightstand. Resident #56 said the nurses would give him/her all their pills in the morning and leave them, then he/she would sort their medication for accuracy before he/she would take them. On 6/8/25 at 12:05 P.M., the surveyor observed a medication cup on Resident #56's overbed table which contained three white round pills and, on their nightstand, the surveyor observed a plastic cup which contained two 2 ml nebulizer vials. During a follow-up interview with observation on 6/9/25 at 8:20 A.M., the surveyor observed a plastic cup on Resident #56's nightstand containing two 2 ml nebulizer vials. Resident #56 said the nurse had brought him/her their medication this morning, the nurse would not leave their medication for him/her to check because the surveyors were in the facility. Resident #56 said he/she wanted the nurse to give him/her their medications and so he/she could check them over prior to taking them. Resident #56 he/she wanted to be able self-administer his/her medications. On 6/10/25 at 8:25 A.M., the surveyor observed a plastic cup on Resident #56's nightstand containing two 2 ml nebulizer vials and, on their chair, a medication cup with a yellow oval pill. Review Resident #56 Physician's Orders indicated but was not limited to: - Acetaminophen (Tylenol) Tablet 325 milligrams (mg), give 2 tablets by mouth every 12 hours as needed for pain, dated 3/14/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for pain, dated 3/14/25 (discontinued 3/14/24) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for temperature of 100 F or above, dated 3/14/25 (discontinued 3/14/24) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 12 hours as needed for temperature of 100 Fahrenheit (F) or above, dated 3/14/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 12 hours for pain, dated 3/14/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 12 hours as needed for pain, dated 5/21/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 12 hours for pain, dated 5/21/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 12 hours as needed for temperature of 100 F or above, dated 5/21/25 (discontinued) - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 6 hours for pain, dated 6/8/25 - Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 6 hours for temperature of 100 F or above, dated 6/8/25 - Colace (stool softener) 100 mg capsule, give 1 capsule in the morning every other day, dated 3/14/25 (discontinued) - Colace 100 mg capsule, give 1 capsule one time daily, dated 4/15/25 (discontinued) - Colace 100 mg capsule, give 1 capsule in the morning, dated 5/21/25 (discontinued) - Colace 100 mg capsule, give 1 capsule every 24 hours as needed for constipation, dated 6/8/25 (discontinued) - Budesonide Inhalation (nebulizer, used to decrease inflammation of the airways) 0.5 mg/2 milliliter, give 2 ml inhalation two times a day for COPD 5/21/2025 Review of Resident #56's medical record failed to indicate: - he/she had a care plan to self-administer their medications, and - a physician's order for self-administration of medications. During an interview on 6/10/25 at 10:22 A.M., the Charge Nurse said if a resident voiced a desire to self-administer their medications, they would need an assessment, a physician's order, and care plan which indicated the medications he/she could self-administer. The Charge Nurse said the medications should not have been left with Resident #56 as they had not been assessed to take all of his/her medications independently. On 6/10/25 at 3:30 P.M., the facility provided the surveyor with a Medication Self-Administration Assessment, dated 3/14/25, which indicated but was not limited to: - Medications: - Tylenol 325 mg, 2 tablets every 6 hours as needed - Colace 100 mg, 1 tablet every 24 hours as needed - Does the resident wish for the staff to prepare medications and leave at bedside per request: YES - Signed by the Charge Nurse on 3/17/25 Further review of the Medication Self-Administration Assessment, dated 3/14/25, failed to indicate Resident #56 was assessed by the Interdisciplinary Care Team to self-administer his/her nebulizer and had not identified any medications other than Colace and Tylenol. During an interview on 6/10/25 at 3:20 P.M., the Director of Nursing (DON) said residents would be assessed for self-administration of medications upon admission and if/when they requested to do so and a physician's order was needed for self-administration of medications.

Based on record review and interview, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations and reporting of allegations and investigative findings for one Resident (#50), out of a total sample of 16 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of potential abuse was reported on a grievance form dated 2/25/25. Findings include: Review of the facility's policy titled Clinical Services, Subject: Abuse, dated March 2023, indicated but was not limited to the following: - Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Action: -Immediately protect Resident from alleged abuse. -Immediately suspend employee pending investigation. -The facility will notify the Department of Public Health (DPH) and Local Law Enforcement no later than two hours after abuse allegation was received. -Investigation: The administrative staff or nursing supervisor assumes responsibility for: -Immediate investigation into the alleged incident (during the shift it occurred on). -Interview resident and other resident witnesses. This interview is to be dated, documented and signed by supervisor. -Interview staff member implicated. Have employee document their knowledge/version of incident in written narrative that is dated and signed. -Interview staff witnesses or other available witnesses. Witnesses are to document incident in a written narrative that is dated and signed. Interview relevant staff on that unit and obtain written statement. -Facility investigation will be completed within 72 hours of the incident. Documentation of investigation to be completed by initiating an Incident and Accident Report, obtaining statements from identified potential witnesses, completing necessary evaluations, and maintaining a timeline of events. -Reporting/Documentation Requirements: The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident and preliminary internal investigation results to the State Health Department and other regulatory agencies per individual state reporting requirements. Resident #50 was admitted to the facility in June 2024 with diagnoses including dementia and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 3/31/25, indicated Resident #50 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The MDS further indicated Resident #50 was independent for most activity of daily living tasks. Review of the facility's Grievance book indicated a grievance reported by Resident #50 dated 2/25/25. The grievance indicated on 2/25/25, Resident #50 reported to the Director of Social Services that a nurse went into the Resident's room and threw a shopping bag at him/her. The Resident was very upset and angry that he/she was yelled at. The grievance indicated that the Director of Social Service met with the Resident and the nurse and had a conversation about approach and the nurse apologized. The grievance form was signed by the Director of Social Services and the Administrator on 2/25/25. During an interview on 6/9/25 at 9:03 A.M., the Administrator said the 2/25/25 grievance was complete and there was no additional investigation or interview documentation to accompany the grievance. Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 6/9/25, failed to indicate the facility submitted a report on 2/25/25 for an allegation of abuse. During an interview on 6/9/25 at 9:35 A.M., the Administrator and surveyor reviewed the 2/25/25 grievance reported by Resident #50. He said the Resident can be difficult at times and he did not consider the incident anything more than the Resident being accusatory and difficult. He said he did not think the report of a nurse throwing at bag at the Resident and yelling at the Resident as a potential abuse. He said he considered it a customer service issue and education was provided to all staff on the facility's customer service expectations. The Administrator said if he felt it was an allegation of abuse, he would have suspended the nurse pending an investigation, conducted an investigation and reported it to DPH. During an interview on 6/9/25 at 11:00 A.M., the Administrator said he had just submitted a report to HCFRS for Resident #50's allegation of potential abuse on 2/25/25. Refer to F609, F610.

Based on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#50), out of a total sample of 16 residents. Findings include: Review of the facility's policy titled Clinical Services, Subject: Abuse, dated March 2023, indicated but was not limited to the following: - Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -The facility will notify the Department of Public Health (DPH) and Local Law Enforcement no later than two hours after abuse allegation was received. Resident #50 was admitted to the facility in June 2024 with diagnoses including dementia and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 3/31/25, indicated Resident #50 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The MDS further indicated Resident #50 was independent for most activity of daily living tasks. Review of the facility's Grievance book indicated a grievance reported by Resident #50 dated 2/25/25. The grievance indicated on 2/25/25, Resident #50 reported to the Director of Social Services that a nurse went into the Resident's room and threw a shopping at him/her. The Resident was very upset and angry that he/she was yelled at. The Resident was told he/she would be moving rooms that afternoon. The grievance indicated that the Director of Social Service met with the Resident and the nurse and had a conversation about approach and the nurse apologized. The grievance form was signed by the Director of Social Services and the Administrator on 2/25/25. Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 6/9/25, failed to indicate the facility submitted a report on 2/25/25 for an allegation of abuse. During an interview on 6/9/25 at 9:35 A.M., the Administrator and surveyor reviewed the 2/25/25 grievance reported by Resident #50. He said the Resident can be difficult at times and he did not consider the incident anything more than the Resident being accusatory and difficult. He said he did not think the report of a nurse throwing at bag at the Resident and yelling at the Resident as a potential abuse. He said he considered it a customer service issue and education was provided to all staff on the facility's customer service expectations. The Administrator said if he felt it was an allegation of abuse, he would have reported it to DPH. During an interview on 6/9/25 at 11:00 A.M., the Administrator said he just submitted a report to HCFRS for Resident #50's allegation of potential abuse on 2/25/25. Refer to F610.

Based on record review and interviews, the facility failed to investigate a potential allegation of abuse for one Resident (#50), out of a total sample of 16 residents. Findings include: Review of the facility's policy titled Clinical Services, Subject: Abuse, dated March 2023, indicated but was not limited to the following: - Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Action: -Immediately protect Resident from alleged abuse. -Immediately suspend employee pending investigation. -Investigation: The administrative staff or nursing supervisor assumes responsibility for: -Immediate investigation into the alleged incident (during the shift it occurred on). -Interview resident and other resident witnesses. This interview is to be dated, documented and signed by supervisor. -Interview staff member implicated. Have employee document their knowledge/version of incident in written narrative that is dated and signed. -Interview staff witnesses or other available witnesses. Witnesses are to document incident in a written narrative that is dated and signed. Interview relevant staff on that unit and obtain written statement. -Facility investigation will be completed within 72 hours of the incident. Documentation of investigation to be completed by initiating an Incident and Accident Report, obtaining statements from identified potential witnesses, completing necessary evaluations, and maintaining a timeline of events. Resident #50 was admitted to the facility in June 2024 with diagnoses including dementia and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 3/31/25, indicated Resident #50 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. The MDS further indicated Resident #50 was independent for most activity of daily living tasks. Review of the facility's Grievance book indicated a grievance reported by Resident #50 dated 2/25/25. The grievance indicated on 2/25/25, Resident #50 reported to the Director of Social Services that a nurse went into the Resident's room and threw a shopping at him/her. The Resident was very upset and angry that he/she was yelled at. The Resident was told he/she would be moving rooms that afternoon. The grievance indicated that the Director of Social Service met with the Resident and the nurse and had a conversation about approach and the nurse apologized. The grievance form was signed by the Director of Social Services and the Administrator on 2/25/25. During an interview on 6/9/25 at 9:03 A.M., the Administrator said the 2/25/25 grievance was complete and there was no additional investigation or interview documentation to accompany the grievance. During an interview on 6/9/25 at 9:35 A.M., the Administrator and surveyor reviewed the 2/25/25 grievance reported by Resident #50. He said the Resident can be difficult at times and he did not consider the incident anything more than the Resident being accusatory and difficult. He said he did not think the report of a nurse throwing at bag at the Resident and yelling at the Resident as a potential abuse. He said he considered it a customer service issue and education was provided to all staff on the facility's customer service expectations. The Administrator said if he felt it was an allegation of abuse, he would have suspended the nurse pending an investigation and conducted an investigation.

Based on observation and interview, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure one of two medication carts was clean and free of loose pills and debris. Findings include: Review of the facility's policy titled Storage of Medication, undated, indicated but was not limited to: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 6/9/25 at 3:53 P.M., the surveyor observed the Unit Two medication cart to have a large amount of loose pills and paper debris on the bottom of the second, third, and fourth drawers. During an interview on 6/9/25 at 3:53 P.M., Nurse #3 said the medication cart should be clean and free of loose pills and debris. Nurse #3 said she was unaware when the medication cart was last cleaned, but it was supposed to have been cleaned weekly on the night shift. During an interview on 6/9/25 at 4:17 P.M., the Director of Nursing (DON) observed the Unit Two medication cart and said the medication cart was cleaned weekly on the 11:00 P.M. to 7:00 A.M. shift and was last cleaned last Friday. The DON said the expectation was for medication carts to be clean and free of loose pills and debris.

Based on observation and interviews, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays. Findings include: Review of Food Committee Minutes indicated the following resident concerns and facility solutions: a) 1/6/25 RESIDENT CONCERNS: Food cold when arrives to resident rooms; SOLUTIONS: The kitchen is trying to keep the food hotter. Kitchen manager is looking into new food trucks. b) 3/6/25 SOLUTIONS: In process of ordering new food delivery carts. c) 4/28/25 SOLUTIONS: In process of ordering new food delivery carts. d) 5/8/25 RESIDENT CONCERNS: The residents saying their food is cold when they get it in their rooms; SOLUTIONS: The Kitchen Manager is still trying to get new food trucks so it will keep the food hotter; CONCLUSION: Four Residents in attendance let the Kitchen Manager know the breakfast and lunch food is hotter. During the initial resident screening on 6/8/25, the survey team identified the following concerns expressed by residents about food palatability: -Resident #60 said the food was always cold, the tea is even cold; -Resident #16 said the food was not always hot but can get reheated; -Resident #48 said the food was cold at times; -Resident #58 said the scrambled eggs were cold; -Resident #39 said the breakfast eggs were cold today; -Resident #61 said the food served was cold, his/her lunch was a bit warmer but not warm enough. On 6/8/25, the surveyor observed the following on Unit 3: -7:54 A.M., one meal truck that enclosed trays within it and two pushcarts with no walls or doors to enclose the breakfast trays. -8:01 A.M., the surveyor observed tray pass begin on Unit 3. -8:25 A.M., Resident #60 indicated the food is always cold and he/she did not receive his/her breakfast yet. -8:38 A.M., the surveyor informed a Certified Nursing Assistant (CNA) of Resident #60 with no breakfast tray. The CNA collected the Resident's breakfast tray from the push cart. -8:40 A.M., Resident #60 received his/her breakfast. The surveyor observed Resident #60's breakfast tray on the open pushcart for 46 minutes prior to the Resident receiving his/her meal. On 6/9/25, the surveyor observed the following: -8:30 A.M., Resident #61 said his/her breakfast was lukewarm; -8:35 A.M., Resident #166 said his/her eggs were cold. On 6/9/25 at 10:30 A.M., 11 Residents attended the Resident Council Meeting. Two of the three Residents from Unit 3 and four of the eight Residents from Unit 2 said the food is cold, not hot enough, and this applied to all meals all days of the week. The Residents said food temperatures are improving but were still not good. On 6/9/25 at 11:12 A.M., the Ombudsman said the residents were concerned with the food not being warm. On 6/9/25 at 11:51 A.M., the surveyor observed the lunch tray line. 12:32 P.M. - a regular texture test tray was made. 12:34 P.M. - the test tray left the kitchen in an enclosed meal truck. 12:35 P.M. - the meal truck arrives on Unit 2. A nurse began reconciling meal tickets with the food on each plate, which consisted of raising and lowering the plate dome. She reviewed two meals which were immediately delivered to residents. Subsequently, she pulled the remaining trays one at a time from the meal truck, reviewed each ticket against the food on the plate, and placed the tray back into the meal truck. 12:41 P.M. - the nurse had finished reconciling the remainder of the trays on the food truck. 12:52 P.M. - the last tray was served from the meal truck. On 6/9/25 at 12:54 P.M., the Food Service Director (FSD) and the surveyor performed the test tray together. The food temperatures were observed to be: -roasted chicken 135F -roasted potatoes and onions 119F -green beans 131F The surveyor and FSD sampled the food. The surveyor observed the food to be visually appealing with good flavor and texture. The surveyor observed the chicken to be adequately warm and the potatoes and green beans to be lukewarm and a less desirable temperature. The FSD said the potatoes and green beans could be warmer. On 6/9/25 at 12:25 P.M.: -Resident #61 said his/her lunch was barely lukewarm and could have been warmer. -Resident #41 said lunch tasted great but was lukewarm. -Resident #14 said lunch could be hotter. -Resident #50 said lunch was lukewarm. On 6/10/25 at 7:45 A.M., the surveyor observed breakfast tray line. 8:05 A.M. - a test tray was made and placed on a pushcart which had no walls or doors to enclose the tray. 8:06 A.M. - test tray leaves kitchen. 8:07 A.M. - test tray arrives on Unit 3. On 6/10/25 at 8:12 A.M., the FSD and surveyor performed a test tray together. The food temperatures were observed to be: -scrambled eggs 120F -oatmeal 127F -muffin (no temperature taken) -juice 48F The FSD and surveyor sampled the food. The surveyor observed the breakfast food to be visually appealing with good flavor and texture. The surveyor observed the scrambled eggs to be lukewarm and the oatmeal to be barely warm and cooler than the eggs. The FSD said he thought the egg temperature was fair and he was surprised by the oatmeal temperature as the oatmeal is typically hotter. On 6/10/25 at 8:25 A.M., Resident #56 said breakfast was cold. On 6/10/25 at 8:33 A.M., Resident #166 said breakfast was cold today, especially the eggs. During an interview on 6/10/25 at 11:50 A.M., the Administrator said he was unaware of pushcarts (with no walls or doors to enclose meals) being used regularly for meal pass. The Administrator said he expected food to be served per regulations and at an appetizing temperature with hot foods served hot.

Based on observation and interview, the facility failed to follow their professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and 2. Ensure the refrigerators in two of two unit kitchenettes were maintained in a sanitary and safe condition. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use. Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. 6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). On 6/9/25 at 12:59 P.M., the surveyor observed, in the main kitchen, several areas of compromised floor grout that was crumbling and/or deeply recessed. The surveyor observed some of these areas to be near the dish room with the tile and grout wet. Additionally, the surveyor observed areas of grout with a thick layer of gray buildup. The surveyor scratched the gray film with a fingernail indicating it was malleable, putty-like substance. On 6/9/25 at 12:59 P.M., the surveyor observed two different types of flooring in the main kitchen, ceramic tile and a vinyl-type flooring. The surveyor observed, near the dish room, raised vinyl flooring where the tile and vinyl flooring met to have small crumbs under the raised vinyl and the grout to be wet. At a different juncture where tile met vinyl flooring, the surveyor observed the vinyl to sit above the tile floor plane. Along that juncture, the surveyor observed a line of gray, putty-like buildup. On 6/9/25 at 12:59 P.M., the surveyor observed compromised floor/wall junctures throughout the main kitchen. There were several areas where coving peeled away from the wall, leaving gaps and/or protruding coving. The surveyor observed cracked and crumbling grout in areas of the floor/wall juncture, and a missing door frame at a floor/doorframe juncture. During an interview on 6/10/25 at 8:45 A.M., the Food Service Director (FSD) said he expected the main kitchen floor to be easily cleanable with no compromised grout or junctures. During an interview on 6/10/25 at 11:50 A.M., the Administrator said he expected the kitchen floor and junctures/coving to be in good repair and easily cleanable. 2. Review of the 2022 Food Code by the FDA, revised 1/2023, indicated but was not limited to the following: 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination Review of the facility's policy titled Cleaning and Sanitation of Dining and Food Service Areas, undated, indicated but was not limited to: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Procedure: -The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. -Staff will be trained on the frequency of cleaning as necessary. -A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. -Staff will be held accountable for cleaning assignments. On 6/9/25 at 9:50 A.M., the surveyor observed in the Unit 2 kitchenette refrigerator, pools of dried orange liquid under the crisper drawers. On 6/9/25 at 9:54 A.M., the surveyor observed in the Unit 3 kitchenette refrigerator, a Resident's plastic grocery bag containing food set on top of an orange and red sticky substance. The surveyor had to use force to lift the bag from the shelf and remove from the sticky substance. On 6/10/25 at 11:01 A.M., the surveyor observed a sticky red and orange substance on the bottom shelf of the Unit 3 kitchenette refrigerator. On 6/10/25 at 11:10 A.M., the surveyor observed the same pools of dried orange liquid under the crisper drawers of the Unit 2 kitchenette refrigerator. The surveyor also observed the bottom crisper drawer had dry, crusted spillage that was a milky white color. In that drawer were single-serve gelatin cups, a Tupperware container of peanut butter, and bottles of water. During an interview on 6/10/25 at 11:50 A.M., the Administrator said he expected Unit refrigerators to be kept clean. He said the refrigerators should be cleaned on a regular and as needed basis. The Administrator said the kitchen and unit staff are responsible for and should coordinate efforts to keep the refrigerators clean. During an interview on 6/10/25 at 11:55 A.M., the FSD said dietary cleaned the unit refrigerators on a weekly basis. The FSD said he expects the kitchenette refrigerators to be clean and free of spills.

Based on interview, and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) were issued with the required information for a Resident (#217) out of three applicable residents reviewed. Specifically, the facility failed to issue the SNF ABN notice and NOMNC, so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Findings include: The NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. The SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Resident #217 was admitted to the facility in January 2025. Review of Form CMS-20052 indicated Resident #217 had a last covered day of Part A Service on 3/21/25. The discharge from Medicare Part A service was facility/provider initiated, and the Resident remained in the facility. Upon request of the ABN and NOMNC for Resident #217, the facility was unable to provide the notices for review. During an interview on 6/9/25 at 8:29 A.M., the Administrator said the social service department was responsible for issuing ABN and NOMNC forms. He said the facility identified the previous social worker was not issuing all of the required notices. He said the Resident should have been informed of the information on the forms. During an interview on 06/09/25 at 8:40 A.M., the Social Worker said she was not working at the facility at the time this notice was supposed to be issued. She said this Resident should have received an ABN to be informed of the estimated cost, reason Medicare may not pay, and the date the resident may have out of pocket expenses.

Based on record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian, or have a qualified dietary employee who met the minimum qualifications to serve as the FSD. Findings include: During an interview on 6/6/24 at 8:45 A.M., the Food Service Director (FSD) said he is not a certified food service manager. He said he was going to take the test, but he has not registered for the class yet. He said he has not taken any formal training classes to be a food service manager at this time. He said he has work experience as a cook at a local restaurant and hospital, and he has completed the ServSafe course. The surveyor reviewed the FSD certificate which indicated he completed ServSafe Food Handler online course and exam 4/6/24. During an interview on 6/6/24 at 1:30 P.M., the Administrator said she was not aware the current FSD did not have the required qualifications to serve as the Food Service Director. She said the Dietitian only works eight hours a week at the facility.

Based on observation and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was pest free and maintained in a sanitary condition; 2. Ensure residents were not served undercooked, unpasteurized shell eggs; 3. Ensure food items were properly labeled and dated in the main kitchen refrigerators; 4. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) and ensure the use of gloves was limited to a single use task; and 5. Ensure staff obtained cooked food temperature prior to serving to residents. Findings include: 1. Review of the facility's policy titled Cleaning and Sanitation of Dining and Food Service Areas, undated, indicated but was not limited to the following: -The food and nutrition service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with written, comprehensive cleaning schedules. -The Director of Food and Nutrition services will determine all cleaning and sanitation tasks needed for the department. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. -6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: -(B) Routinely inspecting the PREMISES for evidence of pests -(D) Eliminating harborage conditions. On 6/6/24 at 8:05 A.M., the surveyor observed the main kitchen floor to be dirty with food particles around the entire kitchen floor, the floor tile grout had a black grimy build-up with embedded food particles, the walls were visibly dirty, and there was dirt and debris underneath the metal tables throughout the kitchen. There was standing water in both dish rooms on the floor, and by the three bay sink. In addition, there were small, black flies on the ceiling by the main serving stationing, dish room to the left of the kitchen, and in and around the floor drain in the first dish room. -On 6/11/24 at 7:50 A.M., the surveyor observed the main kitchen walls and made the following observations: -The walls above the prep sink were stained with food particles, it appeared an attempt was made to wash the walls but only halfway up the wall. -On 6/12/24 at 9:00 A.M., the surveyor and the Food Service Director (FSD) did a final tour of the kitchen and observed the black flies in the first dish room and around the floor drain on the left side of the kitchen, on the walls, and on the ceiling by the service table. There was observed standing water on the floor of the second dish room (last used the evening before per the FSD), the faucet was slowly running in the three bay sink, the sink with the garbage disposal (tape across the top) had standing water, under the flat top grill had large amount of food crumbs under the grill, there was water draining into the floor drain from underneath the counter with the steam oven on it, the floor tile grout throughout the kitchen had built up of a black substance which had food debris imbedded in it. The surveyor was able to scrape the black substance off the floor and remove particles of food. The floor drain in the first dish room was observed to have a build-up of organic matter. During an interview on 6/12/24 at 9:05 A.M., the FSD said the floor was scrubbed last night and this was as clean as they could get the floor. He said the stuff won't come out of the cracks. The FSD said the flies have been a problem and the staff have been educated about keeping the kitchen clean and making sure the water is shut off and cleaned off. He said the dietary staff needs to do a better job. During an interview on 6/13/24 at 12:05 P.M., the Administrator said she was aware of the pest issues as it relates to the kitchen sanitation. She said the floor requires a deeper cleaning and power washing to remove the debris. 2. Review of the facility's policy titled General HACCP (Hazard analysis and critical control point) Guidelines for Food Safety, undated, indicated but was not limited to the following: -Note: The use of pasteurized shell eggs or egg products is preferable. Waivers to allow undercooked unpasteurized eggs are not acceptable. Use pasteurized eggs for safe consumption of undercooked eggs (Sunnyside up fried eggs, soft, cooked eggs, etc.) Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: 3-8 Special Requirements for Highly Susceptible Populations. 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a food establishment that serves a highly susceptible population: (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from raw EGGS, and meringue. On 6/6/24 at 9:10 A.M., the surveyor observed a white box labeled Fresh Shell, Eggs, Large White, Grade AA. Further markings on the box indicated they were United Egg Producers (UEP) Certified (uepcertified.com). The box did not indicate the eggs were pasteurized and the eggs were not marked as pasteurized. Review of uepcertified.com website indicated store labels definitions included but was not limited to the following: -UEP Certified: Eggs marked with these logos are laid on farms following UEP Certified or UEP Certified Cage-Free Guidelines to ensure optimal [NAME] welfare. -Pasteurized: Regulated by FDA, shell eggs are heated to temperatures just below the coagulation point to destroy pathogens. This type of egg may provide benefits for immune-compromised individuals. Review of the facility's food order delivered to the facility on [DATE] and 6/6/24, indicated but was not limited to the following: -On 6/6/24 15 dozen, WHLFCLS eggs shell, large white, USDA AA, with item #4838340 were delivered to the facility. -On 5/30/24 15 dozen, WHLFCLS eggs shell, large white, USDA AA, with item #4838340 were delivered to the facility. -There were no purchases of pasteurized eggs on either invoice. During an interview on 6/6/24 at 9:15 A.M., the Food Service Director (FSD) said their eggs are pasteurized, and they cook the residents' eggs to order. The surveyor and the FSD reviewed the white box of eggs in the walk-in refrigerator and the box was only with the markings UEP Certified. There were no observed markings indicating the eggs were pasteurized. On 6/6/24 at 9:26 A.M., the surveyor observed [NAME] #1 cooking fried eggs and plating undercooked eggs (yolk was runny) for a resident's breakfast meal. The surveyor observed the Dietary Aide covering the plated eggs and loading them onto the delivery truck. On 6/6/24 at 9:31 A.M., the surveyor observed Resident #154's breakfast plate and observed partially eaten undercooked eggs. A review of Resident #154's breakfast meal ticket indicated over medium. On 6/6/24 at 9:34 A. M., the surveyor observed Resident #153 breakfast plate and partially eaten undercooked fried eggs. A review of Resident #153's breakfast meal ticket indicated two poached eggs or fried eggs. On 6/6/24 at 9:50 A.M., the surveyor observed Resident #39's breakfast plate and partially eaten undercooked fried eggs. A review of Resident #39's breakfast meal ticket indicated two over easy eggs. On 6/6/24 at 10:04 A.M., the surveyor observed Resident #303's breakfast plate and partially eaten undercooked fried eggs. A review of Resident #303's meal breakfast ticket indicated scrambled eggs. On 6 6/24 at 10:06 A. M., the surveyor observed Resident #7 breakfast plate and partially eaten undercooked fried eggs. A review of Resident #7's breakfast meal ticket indicated two eggs over medium. On 6/6/24 at 10:07 AM, the surveyor observed Resident #3 breakfast plate and partially eaten undercooked fried eggs. A review of Resident #3's breakfast meal ticket indicated large portion scrambled eggs. During an interview on 6/6/24 at 10:10 A.M., the FSD said he called his regional boss and was told the eggs were pasteurized and they could serve poached or medium eggs. During an interview on 6/11/24 at 2:57 P.M., the Administrator said she thought the eggs were pasteurized. During a telephonic interview on 6/12/24 at 8:28 A.M., the facilities Food Delivery Vendor Customer Representative said food item #4838340 was regular unpasteurized eggs. He said pasteurized eggs have pasteurized in the product name on the order sheet. 3. On 6/6/24 at 8:05 A.M., the surveyor observed the main kitchen and made the following observations: Reach-in refrigerator on the right side: -Fourteen green plastic bowls of diced fruit, six covered with tin foil and eight with ill-fitting plastic lids. Six of the tin foil covered pears cup were sitting inside the cups which had plastic lids and were in contact with the liquid base of the fruit. They were not dated or labeled. -A puddle of clear liquid on the bottom shelf, and a large piece of brown paper saturated with the clear liquid. -Tray of drinks, five had dark liquids, five had red liquid, four had clear liquid, one nosey cup (cut out on top of the cup) with clear liquid, and green plastic bowl covered with tin foil, not labeled, dated, or covered. -One cardboard container of Ready Care thickened, labeled open 3/26/24. Instructions on the container indicated the following: After opening, may be kept up to 7 days under refrigeration. -One open Fortified Nutritional Shake Vanilla, not dated when opened. Instructions on the containing indicated the following: After opening, consume product within 4 days if properly refrigerated. Reach-in refrigerator on the left side: -Large metal bowl of a bean mix, not labeled or dated. -Medium metal pan, uncovered which contained a red puree mix, not labeled, or dated. -Plastic clear container with a yellow food product, not labeled or dated. Walk-in refrigerator: -Plastic clear container with chopped fruit, not labeled or dated. -Plastic clear container of sliced cheese, not labeled or dated. -Metal pan with unidentified food, not labeled or dated. -Metal pan of small pancakes, not dated. -Metal pan of unidentified fruit, not labeled or dated. -Small metal pan containing three hardboiled eggs, not dated. -Clear metal container of jelly, with jelly dripping on the outside of the container, not dated. -Clear round container of an unidentified white food, not labeled or dated. -Clear round container of an unidentified food, not labeled and dated 5/26/24. -Container of low-fat cottage cheese, with a manufacturer's best use by date of 6/1/24, and an open date of 5/9. During an interview on 6/6/24 at 8:31 A.M., the FSD said the food should be labeled and dated and should be thrown out if more than three days old. 4. Review of the facility's policy titled Bare Hand Contact with Food and Use of Plastic Gloves, undated, indicated but was not limited to the following: -Single use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from food handlers' hands to the food product being served. -staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water, and disposable towels and/or heat/air drying methods). -Staff will use clean barriers such as single-use gloves, tongs, usually deli paper and spatulas when handling food. -Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used only for 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. -Gloves are just like hands. They get soiled. Any time a contaminated surface is touched, the gloves must be changed, and hands must be washed: -After coughing or sneezing into hands, using a handkerchief or tissue, using tobacco or touching hair or face. -After handling boxes, crates, or packages. -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. -When switching between working with raw food and working with ready-to-eat food. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: 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. On 6/6/24 at 9:15 A.M., the surveyor observed [NAME] #1 leave the service station wearing gloves, enter the walk-in refrigerator and retrieve two unpasteurized eggs, return to the stove, and crack the eggs into a frying pan. [NAME] #1 was then observed touching resident plates and handling ready-to-eat biscuits with her gloved hands. [NAME] #1 did not change her gloves or perform hand hygiene after cracking the raw, unpasteurized eggs. On 6/6/24 at 9:16 A.M., the surveyor informed the FSD of the observations of [NAME] #1. The surveyor heard the FSD tell [NAME] #1 to remove her gloves and perform hand hygiene. On 6/6/24 at 9:17 A.M., the surveyor observed [NAME] #1 remove her gloves and wash her hands in the prep sink by the stove. [NAME] #1 then dried her hands on the front of her apron and returned to serving breakfast. The paper towel dispenser was observed to be empty. On 6/6/24 at 9:19 A.M., the FSD said [NAME] #1 should have changed her gloves and washed her hands after cracking the eggs. He said she should not have used her apron to dry her hands, and instead should have dried her hands with paper towels. The FSD pointed across the kitchen to the hand washing sink which was observed to have paper towels. On 6/11/24 at 11:45 A.M., the surveyor observed [NAME] #2 leave the tray line wearing gloves, open the oven, remove a tray of hamburgers, and place them on the stove. [NAME] #2 opened a hamburger bun package, retrieved a bun with his gloved hands and placed the hamburger on the bun. [NAME] #2 then returned to lunch service line and continued to plate food. [NAME] #2 was not observed to change his gloves. On 6/11/24 at 11:59 A.M., the surveyor observed a Dietary Aide wearing gloves assembling the resident lunch trays when she sneezed in the direction of her right arm. The Dietary Aide continued to work and was not observed to perform hand hygiene after sneezing. During an interview on 6/11/24 At 2:57 P.M., the FSD said the dietary staff should change gloves anytime their gloves get dirty, they change jobs, or handle raw meats or eggs. 5. Review of the facility's policy titled General HACCP Guidelines for Food Safety, undated, indicated but was not limited to the following: -Educate and monitor food and nutrition service staff on the following: -food temperatures for meal service: -check to be sure staff takes food temperatures correctly and records temperatures. -teach staff what to do if temperatures are in the temperature danger zone. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: - 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above . Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: 3-401.11 Raw Animal Foods. (A) Except as specified under (B) and in (C) and (D) of this section, raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked: (2) 68oC (155oF) for 17 seconds for . nonINTACT MEATS . During observation and interview on 6/11/24 at 7:50 A.M., the surveyor observed [NAME] #2 start breakfast service, plating his first plate. The surveyor asked [NAME] #2 to view his breakfast temperature log. [NAME] #2 said he has not temped the food yet. [NAME] #2 stopped the tray service, looked for a thermometer, temped the tray table, and recorded the holding temperatures. Review of the recorded temperatures indicated that the pureed eggs were 131 degrees Fahrenheit (F) and not being held above 135 degrees F. On 6/11/24 at 11:45 A.M., the surveyor observed [NAME] #2 removing a tray of hamburgers from the oven and placing them on the stove. [NAME] #2 was then observed plating a hamburger on a bun for a resident, and the dietary staff placed the hamburger on the truck for delivery. The surveyor did not observe [NAME] #2 record an internal cooked temperature of the hamburgers (minimum of 155 degrees F) prior to service or a holding temperature to ensure they were held above 135 degrees F. During an interview on 6/11/24 at 2:57 P.M., the FSD said the cooks should take the temperature of the food before serving it to the residents. He said if the temperature is not high enough, the food should be cooked longer.

Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by small black flies and sanitation concerns in the main kitchen, and small black flies in the main dining room throughout the survey. Findings include: Review the facility's policy titled Pest Control, undated, indicated but was not limited to the following: -Routine pest control procedures will be in place. If pests are seen in the kitchen the Director of Food and Nutrition services or designee shall be informed describing where the pest was seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. -6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: -(B) Routinely inspecting the PREMISES for evidence of pests -(D) Eliminating harborage conditions. Review of the facility's Pest Control Binder indicated but was not limited to the following: -There were no pest sightings recorded in the pest sighting log. -Pest Contractor (PC) visit, dated 10/23/23, indicated: Pest findings, drain flies in the kitchen. Heavy organic build-up in grout in around the drains and the dish pit areas. Recommend routine cleaning to deter fly breeding in these areas. Added a logbook to the kitchen. -PC visit, dated 10/27/23, indicated: Drain flies in the kitchen could not locate logbook, sanitation observations included heavy water buildup and organic buildup in dish pit areas. -PC visit, dated 2/1/24, indicated: Sanitation; food debris on kitchen floor. The area needs to be sanitized, and excessive moisture on the kitchen floor, moisture needs to be dried. No pest activity. -PC visit, dated 2/26/24, indicated: Small flies in the kitchen, no entries in the pest logbook, red eye fruit flies observed in the kitchen. Inspected the kitchen area to inspect for possible sources for fruit flies. PC did find multiple sources and pointed them out to the kitchen Manager and how to address them. Sanitation: food debris on kitchen floor, this area needs to be sanitized. Sanitation: excessive moisture under sinks and dishwashing areas that build up in corners and along baseboards along with food debris allowing conducive breeding conditions for fruit flies. Moisture needs to be dried. Sanitation: moisture and food debris not being cleaned off carts in the kitchen. Carts in the kitchen need to be wiped down and dried after use. Sanitation: there were buckets under the sink in the dishwasher area that collected moisture, buckets need to be cleaned and dried out and removed under the sink. -PC visit, dated 3/6/24, indicated: Mainly Black-Eyed fruit flies were found throughout the kitchen. Sanitation conditions: Include standing water under dishwashing stations, food and organic matter build up along baseboards, food collected insides of sink drains and garbage disposals, clean glasses are wet when they are placed on the drying rack. -PC visit, date 3/25/24, indicated: No concerns at this time. Maintenance Director mentioned they had addressed many of the sanitation conditions. I pointed out last visit and since then there has been very little to no small fruit fly activity. Continue maintenance program. -PC visit, dated 5/1/24, small flies beginning to show up again in the kitchen. No entries in the pest logbook. Black Eyed fruit flies in the kitchen. Inspected kitchen for sources of flies, pointed out these conditions to the Maintenance Director and sent photos. Sanitation: food debris on kitchen floor, these areas need to be sanitized. Structural; baseboard pulling away from wall near ovens, baseboards need to be fixed to prevent moisture and food debris from being caught between baseboards. Behavioral: hose left running and water was dripping onto the floor creating stagnant water buildup, hose should be shut off when not in use. Sanitation: debris build up and get caught on top of floor drain covers, drain covers need to be cleaned. Sanitation: sugar packets in and on top of the floor drains, floors need to be swept better before washing. Sanitation: organic matter build-up in the floor drains, floor drains need to be cleaned. -PC visit, dated 5/30/24, indicated: small flies in the kitchen, no logbook entries. Small flies in the kitchen. Please note the fly issue will not improve until the kitchen staff does a better job cleaning and drying things. Continue maintenance program. Sanitation food debris on kitchen floor this area needs to be sanitized structural baseboards pulling away from wall near ovens. Baseboards need to be fixed to prevent moisture and food debris from being caught between baseboards. Behavioral- hose left running and water dripping onto the floor creating stagnant water build up, hose should be shut off when not in use. Sanitation debris build up and getting caught on top of the floor drain covers, drain covers need to be cleaned. Sanitation organic matter build up in floor drains floor drains need to be cleaned. Sanitation, moderate amounts of standing water on the floor, floors need to be dried more thoroughly. Sanitation, clean glasses not dried and left dripping in crates. Glasses and cups should be dried more thoroughly before being placed down and should not be left to drip dry when moisture can collect such as in the crates. During a Resident Group Meeting with the surveyor held in the main dining room on 6/7/24 at 11:00 A.M., fourteen Residents attended the meeting and reported the following: -There are gnats in both parts of the dining room and in the resident rooms. -During Resident Council the surveyor observed residents to be swatting away small black flies. During an interview on 6/06/24 at 3:40 P.M., Resident #16 said there are bugs/flies in the main dining room. On 6/6/24 at 8:05 A.M., the surveyor observed the main kitchen floor to be dirty with food particles around the entire kitchen floor, floor tile grout had a black grimy build-up with embedded food particles, the walls were visible dirty, dirt and debris underneath the metal tables throughout the kitchen. There was standing water in both dish rooms on the floor, and by the three Bay sink. In addition, there were black small black flies on the ceiling by the main serving stationing, dish room to the left of the kitchen, and in and around the floor drain in the first dish room. On 6/6/24 at 3:05 P.M., the surveyor observed the main dining room and observed small black flies on the wall ice machine and coffee station to the left of the entrance to the kitchen, the wall to right of the entrance to the main kitchen, the wall by the windows, the wall by the entrance to the main dining room. The ice machine drain was observed to be draining slowly, leaving standing water. On 6/11/24 at 7:50 A.M., the surveyor observed the main kitchen walls and made the following observations: -The walls above the prep sink were stained with food particles, it appeared an attempt was made to wash the walls but only halfway up the wall. -The prep sink was dirty with a large amount of food particles and standing water. -There were many small black flies on the wall by the main entrance to the kitchen. -There were small black flies on the ceiling over the serving steam table. -There were small black flies on the walls in the room that housed the reach-in refrigerator. -There were small black flies on the walls, the shelving unit drying dishes, in and around the drain in by the first dishwasher room on the left of the kitchen. -The drain in the dish room was found to have standing water and build-up food debris. On 6/11/24 at 8:27 A.M., the surveyor observed walls of main dining room with multiple small flies, along the wall leading to the kitchen, near the ice machine (flying and on the wall), and above the coffee carafes and on the wall adjacent to the coffee carafes. During an interview on 6/11/24 at 8:28 A.M., the Activity Director said the bugs have been increasing with the warmer weather and were not here during the winter months. On 6/11/24 at 11:42 A.M., the surveyor observed multiple small black flies, flying around the area of the ice machine in the main dining room. In addition, there were numerous small black flies on the walls by the windows, behind the ice and coffee machine, entrance to the kitchen and entrance into the main dining room. On 6/12/24 at 9:00 A.M., the surveyor and the FSD did a final tour of the kitchen and reviewed the black flies in the first dish room and around the floor drain on the left side of the kitchen, on the walls and ceiling by the service table. There was observed standing water on the floor of the second dish room (last used the evening before per the FSD), the faucet was slowly running in the three bay sink, the sink with the garbage disposal (tape across the top) had standing water, under the flat top grill had large amount of food crumbs under the grill, there was water draining into the floor drain from underneath the counter with the steam oven on it, the floor tile grout throughout the kitchen had built up of a black substance which had food debris imbedded in it. The surveyor was able to scrape the black substance off the floor and remove a particle of food. The floor drain in the first dish room was observed to have a build-up of organic matter. During an interview on 6/12/24 at 9:05 A.M., the FSD said the floor was power washed last night and that was as clean as they could get the floor. He said the stuff won't come out of the cracks. The FSD said the flies have been a problem and the staff have been educated about keeping the kitchen clean and making sure the water is shut off and cleaned off. He said the dietary staff needs to do a better job. During a telephonic interview on 6/11/24 at 4:45 P.M., the Pest Control Contractor (PCC) said there has been an ongoing issue with small flies in the kitchen and the overall sanitation of the kitchen which has not been addressed. PCC said the sanitation issues included the food and grease build up under the stove and on the floors, standing water on the floors, clogged floor drains, running water found in the sinks, not drying the floors after the dish machine is run leaving standing water. PCC said he had recommended on 5/1/24 and 5/30/24 the baseboard around the kitchen area, between the two dishwashing rooms be fixed. In addition, he has recommended the drains be cleaned out and the organic manner removed from the drains. He indicated the flies could only be eradicated if the kitchen sanitation is maintained and the facility goes ahead with the fogging of the kitchen. During an interview on 6/13/24 at 12:05 P.M., the Administrator said she was aware of the pest issues as it relates to the kitchen sanitation.

Based on record review, interview, and policy review, the facility failed to provide services that met professional standards of quality for one Resident (#303), out of a total sample of 15 residents. Specifically, the facility failed for Resident #303, to implement orders for the care and management of a Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava (SVC) used for intravenous (IV) medications), specifically for monitoring and flushing of a PICC line and changing the equipment for the PICC line. 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 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. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Title: PICC, dated as revised March 11, 2015, indicated but was not limited to the following: -PICC Management activities include dressing the PICC insertion area, accessing the PICC, administering solutions and medications when prescribed. -Nursing care responsibilities, including, but not limited to patient assessment, monitoring, medication administration, potential complications, and documentation criteria. Review of the facility's policy titled Charting and Documentation, undated, indicated 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, shall be documented in the resident's medical record. -The following information is to be documented in the resident's medical record: Treatments or services performed. -Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided, the name and title of the individual who provided care, whether the resident refused the procedure/treatment, and the signature and title of the individual documenting. Review of the facility's policy titled Infusion Devices/Pumps, dated as last revised 12/2021, indicated but was not limited to the following: -The chart documentation should include bag or cassette change at appropriate time interval, monitoring of catheter site at a minimum of every shift, and documentation to be done every shift and as needed (PRN). Resident #303 was admitted to the facility in April 2023 with diagnoses including Alzheimer's dementia, chronic kidney disease, heart disease, and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) assessment, dated 4/16/24, indicated Resident #303 had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) and was dependent on staff for activities of daily living. Review of the Physician's Orders indicated but were not limited to the following: -Monitor PICC line site every shift (three shifts per day) for signs of redness, swelling, or warmth. -Meropenem Solution (antibiotic) 1 gram (gm) IV every 12 hours for bacterial infection for 14 days. -Vancomycin IV Solution (antibiotic) 1000 milligram (mg)/200 milliliters (ml) use 1g IV in the evening for bacterial infection for 14 days. -Change IV tubing every 24 hours at bedtime for IV antibiotic use for 14 days. -Sodium Chloride (NS) Flush Solution 0.9% use 10 ml IV three times a day for flush for 14 days. Flush PICC line with 10 ml NS prior to antibiotic infusion. -NS Flush Solution 0.9% use 10 ml IV three times a day for flush. Flush PICC line with 10 ml NS post antibiotic infusion. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2024 and June 2024 indicated the following: -Monitor PICC line site every shift for signs of redness, swelling, or warmth was not signed off as administered/completed on 5/31/24, 6/1/24, 6/2/24, 6/3/24 (all opportunities) and on 6/4/24 (2 of 3 opportunities). -Meropenem Solution 1 gm IV was signed off as administered as ordered (5/31/24-6/4/24) -Vancomycin IV Solution 1gm IV was signed off as administered as ordered. (6/1/24-6/4/24) -Change IV tubing every 24 hours was not signed off as administered/completed on 5/31/24, 6/1/24, 6/2/24, 6/3/24, and 6/4/24. -NS Flush Solution 0.9% use 10 ml IV three times a day prior to antibiotic infusion was not signed off as administered/completed on 5/31/24, 6/1/24, 6/2/24, 6/3/24 (all opportunities) and on 6/4/24 (2 of 3 opportunities). -NS Flush Solution 0.9% use 10ml IV three times a day post antibiotic infusion was not signed off as administered/completed on 5/31/24, 6/1/24, 6/2/24, 6/3/24 (all opportunities) and on 6/4/24 (2 of 3 opportunities). Review of the nursing progress notes failed to indicate Resident #303 had refused these treatments. Further review of the nursing progress notes indicated the following: -6/1/24 at 6:01 A.M., PICC line patent and no signs of infection. -6/2/24 at 11:55 P.M., PICC line flushed and patent. -6/3/24 at 6:20 A.M., Continues IV antibiotics, PICC line appears intact, no swelling or redness. The notes above indicated that the PICC line had been flushed on 2 of these 3 occurrences, however they failed to indicate if the PICC was flushed before and after the antibiotic administration as ordered and the MAR/TAR were not signed off. Additionally, the note indicated no signs of infection and/or swelling or redness on 2 of these 3 occurrences, however the MAR/TAR were not signed off. During an interview with Consulting Staff #1 and the new Director of Nurses (DON) on 6/12/24 at 10:38 A.M., Consulting Staff #1 said all those treatments should be signed off as administered/completed on the MAR/TAR as ordered and there should not be any blanks/unsigned boxes on the MAR/TAR. She said the treatments should be done per the orders and they were not. The DON nodded in agreement.

Based on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for two Residents (#28 and #38), out of 15 sampled residents. Specifically, the facility failed: 1. For Resident #28, to ensure wound care treatments were reflective of recommendations from the physician wound consultant and in line with the primary physician treatment plan; and 2. For Resident #38, to ensure wound care treatments and preventative recommendations from the physician wound consultant were implemented and provided in accordance with the treatment orders. Findings include: Review of the facility's policy titled Dressing, Dry/Clean, undated, indicated the following: -the purpose of this procedure is to provide guidelines for the application of dry, clean dressings -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 -document the date and time the dressing was changed 1. Resident #28 was admitted to the facility in April 2023. Review of the Minimum Data Set (MDS), assessment, dated 3/15/24, indicated Resident #28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. Review of the nursing progress notes indicated that on 5/13/24 Resident #28 sustained a skin tear to the left shin with a new order to cleanse the left shin with normal saline, pat dry, apply Xeroform (a mesh medicated gauze), apply an ABD pad (gauze dressing that absorbs fluid) and wrap with Kling (rolled gauze) loosely twice per day until seen by wound consultant. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 5/16/24, indicated Resident #28 had a skin tear to the left shin measuring 4.9 centimeters (cm) in length by 3.2 cm in width by 0.2 cm in depth. The recommended treatment indicated to cleanse with saline at the time of dressing and use a Hydrocolloid sheet (a thin, sterile, occlusive dressing with a flexible outer layer that helps isolate the wound) three times per week. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 5/30/24, indicated the skin tear to the left shin measured 5 cm in length by 5 cm in width by 0.2 cm in depth. The wound consultant recommendation indicated to discontinue the Hydrocolloid sheet, start a Collagen sheet, an ABD pad, followed by a gauze roll, followed by tape for retention once per day. Review of the Treatment Administration Record (TAR) for Resident #28 indicated the recommended order of a Collagen sheet was initiated on 6/6/24, 7 days after it was recommended. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 6/6/24, indicated the skin tear to the left shin measured 4 cm in length by 4.5 cm in width by 0.2 cm in depth. The wound consultant recommendation indicated to discontinue the Collagen sheet, start Adaptic (designed to help protect the wound while preventing the dressing from adhering to the wound), followed by an ABD pad, followed by a gauze roll and tape for retention. Review of the TAR on 6/11/24 indicated the treatment order continued as Collagen sheet, ABD pad, gauze roll and tape. During an interview on 6/11/24 at 5:15 P.M., Resident #28 said no one had changed his/her dressing on this day, but it had been changed the day before. The Resident said the staff change the dressing every other day. The surveyor observed the Resident to have an adhesive bandage to the left shin, the surveyor did not observe gauze wrap. During an interview on 6/12/24 at 7:45 A.M., Nurse #1 said the process with the wound consultant was that if there was an extra nurse (a nurse not assigned to a medication cart) that nurse would complete wound rounds with the physician, otherwise the assigned unit nurse would complete the wound rounds with the wound consultant. She said she had not completed wound rounds with the wound consultant on 6/6/24. She said she was not sure who checked the Wound Evaluation and Management Summary to determine changes to the treatment or what the process was. She said Resident #28 has a dressing that is changed every Monday, Wednesday and Friday (indicating the previous order, which was discontinued on 6/6/24). During an interview on 6/12/24 at 8:00 A.M., Nurse #1 said she had changed the dressing for Resident #28 this morning and when removing the adhesive bandage, the skin tear started to bleed. She said she was not sure who put the adhesive bandage on Resident #28. During an interview on 6/12/24 at 9:10 A.M., Resident #28 said the skin tear had been improving until this morning when the adhesive bandage was removed and started bleeding. The surveyor observed the left shin to now have a gauze wrap. The Resident said the staff had not previously been wrapping the skin tear. During an interview on 6/12/24 at 2:00 P.M., the Assistant Director of Nurses said a nurse should have accompanied the wound consultant during wound rounds to verify any changes in treatment. She said the treatment orders should have been followed by the nurses and an adhesive bandage should not have been used on 6/11/24. She said the primary physicians have deferred to the wound consultant for treatment recommendations and the orders should be updated to reflect the wound consultant recommendations following the visits. During an interview on 6/13/24 at 1:50 P.M., Physician #2 said the expectation was for the facility to follow the recommendations from the wound consultant. 2. Resident #38 was admitted to the facility in March 2024 with a vascular ulcer to the left great toe. Review of the MDS assessment, dated 3/9/24, indicated Resident #28 scored 15 out of 15 on the BIMS indicating the Resident was cognitively intact. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 3/28/24, indicated Resident #38 had a wound to the left great toe measuring 1.2 cm in length by 1.1 cm in width by 0.2 cm in depth. The recommended treatment indicated to apply Calcium Alginate, followed by a gauze island border dressing every day. Additional recommendations indicated to apply lambswool between toes. Review of the TAR indicated the left great toe treatment order for Calcium Alginate was initiated on 4/2/24 and was not provided on 4/3, 4/4, 4/5, 4/7, 4/8, and 4/9/24. There was no indication the recommendation to apply lambswool between toes was implemented. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 4/11/24, indicated Resident #38's wound to the left great toe measured 1 cm in length by 1 cm in width by 0.4 cm in depth. The recommended treatment indicated to apply a Collagen sheet followed by a gauze island border dressing every day. The recommendation to apply lambswool between toes continued. Review of the TAR indicated the left great toe treatment order for Collagen sheet was initiated on 4/13/24 and was not provided on 4/14, 4/17, 4/19, 4/22, 4/23, 4/26, 4/27, 5/1, 5/6, 5/7, 5/9, 5/13, 5/21 and 5/22/24. There was no indication the recommendation to apply lambswool between toes was implemented. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 5/23/24, indicated Resident #38's wound to the left great toe measured 0.7 cm in length by 0.7 cm in width by 0.2 cm in depth. The recommended treatment indicated to continue the Collagen sheet, add Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin), followed by a gauze island border dressing every day. The recommendation to apply lambswool between toes continued. Review of the TAR indicated the order for the Collagen sheet followed by the gauze island border dressing continued from 4/13/24 through 6/7/24. The addition of Santyl was not ordered as recommended in the treatment plan by the wound consultant on 5/23/24. Review of the TAR indicated no treatments were completed to the left great toe on 5/24, 5/27, 5/31, 6/4, and 6/5/24. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 6/6/24, indicated Resident #38's wound to the left great toe measured 0.4 cm in length by 0.5 cm in width by 0.2 cm in depth. The recommended treatment indicated to discontinue the Collagen sheet and Santyl and to start Calcium Alginate followed by a gauze island with border dressing. The recommendation to apply lambswool between toes continued. During an interview on 6/6/24 at 8:45 A.M., Resident #38 said the wound consultant had been in this morning to look at the left great toe and had put on a new treatment. He/she said the staff do not change the dressings every day and that sometimes he/she had to remind the staff. During an interview on 6/7/24 at 1:52 P.M., Resident #38 said the wound consultant had changed the dressing at 8:00 A.M. the previous morning and no one had changed the dressing since. The surveyor observed a bandage to be attached by only one out of four sides and no longer covering the wound to the left great toe. The surveyor did not observe lambswool to be in place. Review of the TAR indicated the recommended treatment from 6/6/24 was implemented on 6/8/24. No treatment was provided to the left great toe on 6/7/24. During an interview on 6/11/24 at 3:48 P.M., Resident #38 said Nurse #1 had changed the dressing to the left great toe on this day. The surveyor observed the area to be bandaged and did not observe lambswool between the toes. During an interview on 6/12/24 at 7:50 A.M., Nurse #1 said the process for the wound consultant was that if there was an extra nurse that nurse would complete wound rounds with the physician otherwise the assigned unit nurse would complete the wound rounds with the wound consultant. She said she had not completed wound rounds with the wound consultant on 6/6/24. She said she was not sure who checked the Wound Evaluation and Management Summary to determine changes to the treatment or what the process was. She said the primary physicians defer to the wound consultant for treatment recommendations. She said she could not say why the orders did not match the recommendations or why the treatments were not provided as ordered. During an interview with observation on 6/12/24 at 11:38 A.M., Nurse #1 said she did not know about the lambswool recommendation for Resident #38 and lambswool was not being used. During an interview on 6/12/24 at 2:00 P.M., the Assistant Director of Nurses said the recommendations from the wound consultant should be followed, the treatment changes should be implemented timely, and the treatments should be completed as ordered. She said the recommendation for lambswool between the toes should have been reviewed for implementation. During an interview on 6/13/24 at 1:50 P.M., Physician #2 said the expectation was for the facility to follow the recommendations from the wound consultant.

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #1), the Facility failed to ensure they were free from physical and/or verbal abuse by staff members when; 1) On 2/19/24, Resident #2, who was alert and oriented, reported to a staff member that during an 11:00 P.M. to 7:00 A.M. shift (later determined to be on 2/18/24) he/she had a fall, that Nurse #2 picked him/her up, put him/her back into bed, that Nurse #2 then put his hand over his/her mouth and verbally threatened him/her saying he (Nurse #2) would hurt his/her (Resident #2's) family if he/she told anyone. Resident #2 told staff he/she was scared of Nurse #2, and he/she became visibly upset and cried even weeks later, when interviewed regarding the incident. 2) On 03/06/24, Resident #1, who had significant cognitive impairment and was dependent on staff to meet his/her care needs, spit food out at CNA #1 and in response, CNA #1 grabbed both of Resident #1's arms, forcefully shook him/her, and then backhanded Resident #1 on the mouth. A skin assessment was conducted and Resident #1 was found to have new bruised areas on his/her left side and left arm. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 03/2023, indicated the following: -it is the policy of the Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation, -it is the philosophy of the Facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included major depressive disorder, chronic pain, spinal stenosis (narrowing of the spinal canal), and anxiety disorder. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 02/02/23 indicated he/she had intact cognition, was able to make his/her needs known and was his/her own decision maker. The MDS indicated Resident #2 required moderate assistance from one staff member to meet his/her care needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 02/19/24, indicated that on 02/19/24, Resident #2 reported that after he/she had a fall, that a nurse (later identified as Nurse # 2) assisted him/her (back to bed), then the nurse placed his hand over his/her (Resident #2's) mouth and said, do not say anything about this or your family will be in trouble. During an interview on 03/19/24 at 11:10 A.M., Resident #2 said he/she could not remember the date, but that sometime late at night or early morning, he/she heard a girl yell, he/she is flat on his/her face! Resident #2 said next thing he/she knew, Nurse #2 was picking him/her up, and then threw him/her onto his/her bed. Resident #2 said then Nurse #2 put his hand over his/her mouth and told him/her not to tell anyone or he would come back and hurt his/her family. Resident #2 said he/she felt very threatened by Nurse #2. Resident #2 was observed to be visibly upset and tearful during the interview with the Surveyor, which was one month after the alleged incident occurred. Review of a Social Services Progress Note, dated 03/01/24, indicated that when Social Worker (SW) #1 asked Resident #2 about his/her abuse allegation, he/she said he/she had tried to avoid Nurse #2. The Note indicated that Resident #2 was still upset, and said he/she was trying to understand why he (Nurse #2) would do something like that to him/her, and said, I'm a good person, what did I do wrong? The Note indicated that SW #1 provided reassurance, support, and validation of his/her recent trauma. Review of a Police Report, dated 02/19/24, indicated Resident #2 said he/she had been lying in bed at night when Nurse #2 came into his/her room, grabbed him/her and assisted him/her out of bed. The Police Report indicated Nurse #2 pulled Resident #2, he/she fell and hit his/her face on the floor. The Police Report indicated that the Officer observed a bruise on Resident #2's upper lip. The Police Report indicated that Resident #2 said Nurse #2 threw him/her down onto the bed, and told him/her to be quiet or he would be back, which Resident #2 took as a threat. The Police Report further indicated that Resident #2 said Nurse #2 knew his/her family, their addresses, and that Resident #2 was clearly scared and hesitant to tell anyone because he/she was concerned for his/her family's well-being. The Police Report indicated that a few days had passed after the incident before the resident told CNA #2. The Police Report indicated that Facility Administration reported to the Officer that Resident #2 had told CNA #2 that when Nurse #2 threw him/her on the bed, he covered his/her (Resident #2's) mouth and told him/her that if he/she told anyone, he would hurt his/her family. During a telephone interview on 03/26/24 at 9:24 A.M., and review of her Written Witness Statement, dated 02/19/24, Certified Nurse Aide (CNA) #2 said she knew Resident #2 very well and had been regularly assigned to care for him/her. CNA #2 said she could not remember the exact date, but said when she went to care for Resident #2 in the morning, Resident #2 said to her, thank God you are here, because that man threw me in bed last night, put his hand over my mouth, and told me not to say anything or he would do something to my family. CNA #2 said Resident #2 was crying, shaking, and hugged her when he/she (Resident #2) told her what happened. CNA #2 said she told Nurse #1 immediately. Review of the Facility's Investigation Summary Report, undated, indicated that on 02/19/24 Resident #2 reported that Nurse #2 picked him/her up (off the floor), threw him/her in bed, and then put his hands over Resident #2's mouth and told him/her not to tell anyone or he was going to come for his/her family. The Report indicated that on 02/19/24, Nurse #1 said that staff noticed a bruise on Resident #2's upper lip and when Nurse #1 asked him/her how he/she got the bruise, Resident #2 said he/she had already had it and denied any falls. The Report indicated that Resident #2 had said to CNA #2 that, the big man (later identified as Nurse #2) picked me up, threw me onto the bed, put his hands over my mouth and told me not to tell anyone or he was going to come after my family. The Report indicated that CNA #5, who worked the night shift starting on 02/18/24 into 2/19/24 with Nurse #2 on Resident #2's unit, was interviewed on 02/19/24, and that CNA #5 said that at approximately 11:50 P.M. (sometime at the start of the shift) when she answered Resident #2's call light, and she found him/her on the floor. The Report indicated that CNA #5 told Nurse #2, and he (Nurse #2) picked Resident #2 up. The Report indicated that Nurse #2 would not comply with the Facility's investigation, and the Facility substantiated Resident #2's allegation of abuse. Review of a CNA #5's Written Witness Statement, undated, indicated that on 02/11/24, (per the Director of Clinical Operations, correct date was 02/19/24) at approximately 11:50 P.M., she went to Resident #2's room to answer his/her call light and found Resident #2 on the floor. The Statement indicated that CNA #5 told Nurse # 2 that Resident #2 was on the floor and that he (Nurse #2) picked Resident #2 up. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. Review of Resident #2's Medical Record indicated there was no documentation to support Nurse #2 documented that Resident #2 had a fall anytime during the overnight shift from 02/18//24 into 02/19/24. Review of a Skin Assessment, dated 02/19/24, indicated Resident #2 had a bruise on the left side of his/her mouth. During a telephone interview on 3/27/24 at 10:24 A.M., and review of her Written Witness Statement, dated 02/19/24, Nurse #1 said she knew Resident #2 very well, and was assigned to him/her during 7:00 A.M. to 3:00 P.M. shifts. Nurse #1 said that on 02/19/24 in the morning, she noticed bruising on Resident #2's left upper lip, that had not been there the last time she worked with Resident #2 (2-3 days prior) and asked him/her what happened. Nurse #1 said Resident #2 initially denied anything had occurred which would have caused the bruise. Nurse #1 said that after she left Resident #2's room, CNA # 2 approached her and told her that Resident #2 had just reported to her that Resident #2 got scared when he/she heard her (CNA #2) jiggle the doorknob to enter the bathroom. Nurse #1 said CNA #2 then told her that Resident #2 had told her (CNA #2) that some night over the weekend, a large man picked him/her up, threw him/her onto his/her bed, put his hand over his/her mouth and then told him/her not to say anything or he would hurt his/her family. Nurse #1 said she went back to speak with Resident #2 again and that Resident #2 repeated to her the exact allegation that CNA #2 had just reported to her. Nurse #1 said Resident #2 apologized for lying about the bruise on his/her lip, but said he/she was afraid to say anything because Nurse #2 told him/her that he would hurt his/her family if he/she did. Nurse #1 said that when Resident #2 told her what happened, he/she was crying, shaking, and afraid. Nurse #1 said Resident #2 told her that he/she was afraid for his/her family. Nurse #1 said it took Resident #2 until last week (about one month) to return to his/her emotional baseline. Nurse #1 said she was also present during Resident #2's follow-up interview with the Police Detectives approximately two weeks after the incident occurred and said when Resident #2 had to restate his/her account of the alleged incident, he/she was crying, shaking, and told them he/she was scared. Nurse #1 said there was never any variation in Resident #2's account of the alleged incident. During an interview on 03/20/24 at 1:27 P.M., the Assistant Director of Nurses (ADON) said Nurse #1 reported Resident #2's allegation on 02/19/24 in the morning. The ADON said she went to interview Resident #2 and he/she seemed afraid to tell her any information. The ADON said Resident #2 then told her that a big [NAME] picked him/her up from the floor, threw him/her into bed, then put his hand over his/her mouth and told him/her (Resident #2) not to say anything. The ADON said Resident #2 apologized for initially lying about his/her fall but said he/she lied because he/she was afraid for his/her family. During an in-person interview on 03/20/24 at 3:04 P.M., and a telephone interview on 03/29/24 at 9:35 A.M., the Director of Clinical Operations said that upon completion of the Facility's investigation, Nurse #2 had been terminated. The Director said she and the ADON attempted to interview Nurse #2, and although he had refused to answer any of their questions, said that Nurse #2 had acknowledged that Resident #2 had a fall, and that he refused to document it. The Director said CNA #5's Written Witness Statement had mistakenly indicated the date of the incident was 02/11/24, but said it should have been 02/19/24. The Director said based on Resident #2's allegation and interviews, CNA #5's Written Witness Statement and facility interview, the Facility substantiated an allegation of abuse and terminated Nurse #2. During a telephone interview on 03/19/24 at 1:10 P.M., Nurse #2 said he had retained an attorney and refused to participate in an interview with the Surveyor, stating he was invoking his Fifth Amendment Rights, and then began quoting his [NAME] Rights. Nurse #2 said he would always cooperate with the Department of Public Health however, he refused to participate in an interview. Although there were no witnesses to corroborate Resident #2's allegation that Nurse #2 threatened him/her and covered his/her mouth, a reasonable person would be convinced abuse occurred based on Resident #2's intact cognition and consistent statements regarding the allegation, as well as Nurse #2's failure to be forthcoming at the time of Resident #2's fall and Nurse #2's refusal to participate in investigations conducted by the Facility and the Department of Public Health. 2) Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 03/06/24, indicated that Nurse #1 reported that she witnessed a Certified Nurse Aide (CNA, later identified as CNA #1) with her hand raised toward Resident #1's mouth. Resident #1 was admitted to the Facility in April 2023, diagnoses included Alzheimer's Disease, dementia, and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/24, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. Review of a Skin Assessment,dated 02/29/24, indicated Resident #1 had intact skin, with no issues noted. Review of the Facility's Investigation Summary Report, undated, indicated that on 03/06/24 at approximately 9:45 A.M., Nurse #1 reported that she observed Certified Nurse Aide (CNA) #1 with her hand raised toward Resident #1's mouth. The Summary indicated that during an interview conducted by the Assistant Director of Nurses (ADON), Nurse #1 told her that she witnessed CNA #1 slap Resident #1 on the mouth. Review of CNA #1's Written Witness Statement, dated 03/06/24, indicated that Resident #1 spit on her (CNA #1) and that she tapped Resident #1 on the mouth for spitting. During an interview on 03/20/24 at 9:24 A.M., CNA #1 said that on 03/06/24 that Resident #1 had been spitting food out and that when she tried to wash his/her face with a facecloth, Resident #1 spit in her (CNA #1's) face. CNA #1 said she then tapped Resident #1 on the lips and said, no, no, no don't do that. However, further review of the Facility's Investigation Summary Report indicated that during an interview conducted by the Assistant Director of Nurses (ADON), CNA #1 told the ADON that Resident #1 spit his/her medications at her, and that she (CNA #1) backhanded Resident #1 so he/she would stop spitting. The Summary indicated that an allegation of abuse had been substantiated. Review of a Police Report, dated 03/06/24, indicated that CNA #1 said that at approximately 9:30 A.M., Resident #1 spit ice cream at her. The Report indicated that in response to the spitting, CNA #1 admitted that she smacked Resident #1's mouth with the back of her hand and told him/her no. The Report indicated that the Police Officer had been informed that Resident #1 had a bruise on his/her arm from being grabbed and that CNA #1 said she had grabbed Resident #1's hands to assist him/her up so she could provide care, but said she was unaware if she had left any bruising. Review of a Nurse Progress Note, dated 03/06/24, indicated that at 9:30 A.M. that morning, Resident #1 had been involved in an incident involving a staff member. The Note indicated that CNA #1, with an open back hand, hit Resident #1 on the mouth. Review of a Skin Assessment, dated 03/06/24, indicated Resident #1 had scattered bruises on bilateral arms and left breast area. During an interview on 03/19/24 at 2:12 P.M. and review of her Written Witness Statement, dated 03/06/24, Nurse #1 said that on 03/06/24 during breakfast, Resident #1 had been combative and had been spitting his/her food out. Nurse #1 said she witnessed CNA #1 hit Resident #1 in the mouth with the back of her hand. Nurse #1 said that during a skin check following the incident, she noticed bruising on Resident #1's left breast area and both forearms. Nurse #1 said she works during the day Monday through Friday on Resident #1's unit, is very familiar with him/her, and said she had not seen the bruises on Resident #1's arms or left breast area prior to 3/06/24. During a telephone interview on 03/28/24 at 10:07 A.M. and review of her Written Witness Statement, dated 03/06/24, CNA #3 said at the start of her day shift (7:00 A.M. to 3:00 P.M.) on 03/06/24, CNA #1 seemed agitated. CNA #3 said during breakfast in the dining room, she saw CNA #1 trying to feed Resident #1, but he/she was resistant. CNA #3 said she was fluent in Resident #1's language and said Resident #1 kept saying he/she did not want to eat. CNA #3 said she told CNA #1 that Resident #1 was saying he/she did not want to eat and that CNA #1 told her that he/she had to eat, and that he/she did this all of the time. CNA #3 said she saw CNA #1 grab Resident #1's cheeks, force food into his/her mouth, and then Resident #1 spit the food out at CNA #1. CNA #3 said she then saw CNA #1 grab both of Resident #1's arms and shake him/her forcefully. CNA #3 said at that point, she immediately went to get Nurse #1. During an interview on 03/20/24 at 1:27 P.M., the Assistant Director of Nurses (ADON) said on 03/06/24, Nurse #1 reported to her that she had just witnessed CNA #1 backhand (smack) Resident #1 in the mouth. The ADON said she and Director of Clinical Operations interviewed CNA #1 together. The ADON said CNA #1 told them that Nurse #1 gave Resident #1 medications and then he/she started to spit them at her (CNA #1). The ADON said CNA #1 told them that she backhanded (smacked) Resident #1 and that CNA #1 then demonstrated to them, what she had done. The ADON said that on 03/06/24 CNA #3 told her that during breakfast, she saw Resident #1 hitting and spitting at CNA #1 and he/she would not stop. The ADON said CNA #3 told her that CNA #1 then shook Resident #1's arms. The ADON said she saw bruises on Resident #1's left breast area and left arm. Review of a Skin Assessment, dated 03/19/24, indicated Resident #1 had a fading yellow bruise over his/her left breast area. During an in-person interview on 03/20/24 at 3:04 P.M., and a telephone interview on 03/29/24 at 9:35 A.M., the Director of Clinical Operations said she and the ADON interviewed CNA #1 together. The Director said CNA #1 told them that when Resident #1 spit at her, she (CNA #1) backhanded him/her in the mouth, and at the same time she (CNA #1) demonstrated the backhand motion to them. The Director said that she and the ADON determined that the bruise on Resident #1's left breast area and both arms were a result of the physical abuse by CNA #1. The Director said the Facility had substantiated the abuse and CNA #1 had been terminated. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was assessed by nursing to be at an increased risk for elopement, had a history of wandering the unit, and told staff he/she wanted to go home, the Facility failed to ensure staff responded appropriately to a sounding exit door alarm, in an effort to maintain Resident #1's safety and prevent an incident/accident (elopement), resulting in an injury. On 2/23/23, sometime during the evening shift (3:00 P.M. to 11:00 P.M.), Resident #1 who was last seen in the day room on his/her unit, exited the Facility, unbeknownst to staff. The Facility received a call from someone in the community saying they heard someone outside the Facility yelling for help. Resident #1 was found outside on the Facility grounds, lying in the prone (face down) position on the ground, he/she was transported to the Hospital Emergency Department (ED) for evaluation, where he/she was diagnosed with a hematoma (bruise) above his/her left eye and a left rib fracture. Findings include: The Facility's Policy, titled Missing Person-Elopement, dated as revised June 2015, indicated the following: -it is the policy of the Facility to minimize the potential of resident elopement and to establish a process to locate a resident if they are unable to be found in the Facility or on the grounds -an elopement assessment is completed on residents upon admission, quarterly, annually, and as needed. Residents scoring 10 or greater is considered an elopement risk and will have their picture posted at the front desk and on each unit -door breach: if door alarm sounds and staff cannot identify who has triggered the alarm, residents identified as an elopement risk must be checked and located by a staff member Resident #1 was admitted to the Facility in March 2021, diagnoses included Alzheimer's disease, Dementia with behavioral disturbances, Abnormalities of gait and mobility, Anxiety, Dysthymic disorder, bilateral knee pain, and muscle weakness. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 12/15/22, indicated that Resident #1 had severe cognitive impairments, exhibited wandering behavior, and he/she required extensive assistance of one staff person with ambulation, and locomotion on/off the unit. The MDS indicated Resident #1's balance was not steady during transitions and walking. Review of Resident #1's Behavioral Care Plan, (reviewed and renewed with the Quarterly MDS dated [DATE]), indicated that he/she had behavioral symptoms that included intrusive wandering and attempting to elope. Review of Resident #1's Fall Risk Assessment, dated 12/21/22, indicated that he/she was assessed by nursing as being a high risk for falls. Review of Resident #1's Falls Care Plan, (reviewed and renewed with the Quarterly MDS dated [DATE]), indicated that he/she required an assist of one for ambulation and was at risk for falls related to bilateral knee pain. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, updated as 1/05/23, indicated that Resident #1 required assist of one with ambulation and locomotion on/off the unit, and that he/she could become angry, wanting to go home, and was an elopement risk. Review of a Nurse Progress Note, dated 2/08/23, indicated that Resident #1 was verbally and physically abusive to staff, and attempting to elope. Review of Nurse Progress Notes, dated 2/17/23, indicated that Resident #1 was combative, yelling/screaming, and trying to elope. Review of Resident #1's Activity of Daily Living (ADL's) Flow sheet, for February 2023, indicated that on 2/23/23 Resident #1 exhibited wandering behavior on the 3:00 P.M.-11:00 P.M. shift. Review of the Facility's Internal Investigation Report, dated 2/24/23, indicated that at approximately 8:50 P.M., Resident #1 became combative and was redirected by staff, he/she was brought to a common area to watch television while staff tended to other residents. The Report indicated Resident #1 eloped outside through a door and fell before staff could reach him/her and that he/she was transported to the Hospital Emergency Department. Review of a Nurse Progress Note, dated 2/24/23 at 12:19 A.M., indicated at approximately 8:50 P.M., (2/23/23) this writer (identified as Nurse #1) was notified by a CNA (identified as CNA #2) that there was a resident outside. The Note indicated Nurse #1 went outside found Resident #1 lying on his/her abdomen with another nurse present (identified as Nurse #2), he/she was assessed and sent to the Hospital Emergency Department (ED) for evaluation. During an interview on 3/09/23 at 3:00 P.M., Certified Nurse Aide (CNA) #3 said on 2/23/23, she worked the evening shift and she was assigned to provide care to Resident #1 and that he/she became combative saying I am going home. CNA #3 said that this was not unusual for Resident #1. CNA #3 said she asked CNA #4 to take Resident #1 for a walk because he/she (Resident #1) wanted nothing to do with her (CNA #3). CNA #3 said that she told CNA #4 to stay with him/her while she provided care to another resident. CNA #3 said she was going back to go look for Resident #1 when CNA #2 came running towards the nurse's station saying Resident #1 was outside on the ground. CNA #3 said she did not know how Resident #1 eloped because she did not hear a door alarm sound until she opened the exit door near the nurse's station to go outside with CNA #2 and Nurse #1 after Resident #1 was found outside. During an interview on 3/13/23 at 3:35 P.M., Certified Nurse Aide (CNA) #4 said she worked on 2/23/23 during the evening shift on Resident #1's unit. CNA #4 said that CNA #3 asked her to take Resident #1 for a walk because he/she did not want CNA#3 to care for him/her and that he/she wanted to go home. CNA #4 said she walked with Resident #1 then sat him/her in a chair in the day room by him/herself and left the room. CNA #4, at some point later in the shift (exact time unknown) CNA #2 came to the unit yelling the neighbors called, and Resident #1 is outside lying on the ground. CNA #4 said that when CNA #2 and CNA #3 opened the exit door near the nurse's station the alarm sounded and said she had not hear any door alarm sound until they opened that door. CNA #4 said she should not have left Resident #1 alone because he/she had Dementia, wandered the unit, and was at risk for eloping. During an interview on 3/13/23 at 2:45 P.M., Nurse #3 said on 2/23/23 during the evening shift, she heard a door alarm sounding and saw Nurse #2 shut the alarm off from behind the nurse's station, but said she could not recall the exact time the alarm went off. Nurse #3 said a few minutes after Nurse #2 had shut the alarm off Nurse #2 told her a neighbor called saying someone was outside the Facility yelling for help and she was going outside to check around the building. Nurse #3 said that CNA #2 stayed at the nurses station watching the camera monitors and then CNA #2 left the unit to go outside because Nurse #2 had not come back into the Facility. Nurse #3 said CNA #2 then came back into the Facility and told her (Nurse #3) to 911 because there was a resident outside, and he/she was hurt. During an interview on 3/08/23 at 3:00 P.M., Certified Nurse Aide (CNA) #2 said she worked on 2/23/23 during the evening shift on another unit. CNA #2 said that she returned from her dinner break at approximately 8:25 P.M., and about ten minutes later Nurse #2 told her that neighbors had called the Facility and informed her they heard someone outside yelling help me and said Nurse #2 told her to watch the cameras monitors at the nurse's station while she went outside to do a perimeter check of the building. CNA #2 said on the monitors she saw someone walking up the driveway and she immediately ran outside, down the driveway and said there was a man saying there is a resident on the ground and then she heard Nurse #2 yell, I need help. CNA #2 said she ran back into the Facility and yelled to Nurse #3 to call 911 immediately. CNA #2 said she then ran to the unit where Resident #1 resided to inform staff that he/she was outside on the ground and Nurse #2 needed help. CNA #2 said she did not hear any door alarms sound until she and CNA #3 opened the exit door to go outside to help. During an interview on 3/09/23 at 8:36 A.M., Nurse #1 said the last time she saw Resident #1 was around 7:45 P.M., that he/she was sitting in the main day room near his/her unit, and she (Nurse #1) left the room at that time to go pass medications to other residents. Nurse #1 said that CNA #2 came to the unit (exact time unknown) and started yelling, Nurse, Nurse your resident is outside on the ground. Nurse #1 and said that one of the CNA's (name unknown) opened the exit door near the nurse's station and the alarm sounded as she ran outside with the CNA's. Nurse #1 said she saw Resident #1 lying on his/her abdomen at the bottom of cement steps on the ground and Nurse #2 was with him/her. Nurse #1 said that she and Nurse #2 assessed Resident #1 and did not move him/her from the position he/she was in until the Emergency Medical Technicians (EMT's) arrived. Nurse #1 said that she never heard a door alarm sound until the exit door by the nurse's station was opened by a CNA (name unknown). Nurse #1 said she was not aware Resident #1 had eloped off the unit. During an interview on 3/08/23 at 12:36 P.M., the Maintenance Director said that there are alarm keypads on each unit located at the nurse's stations and said the nurses have the codes to shut off the alarm in the Facility from the nurse's station when an exit door is opened. The Maintenance Director said when a door alarm sounds the alarm keypad shows what door has been opened. Review of Nurse #2's Written Witness Statement, dated 2/23/23, indicated that she found Resident #1 lying in the prone position on the ground on the side of the building and instructed CNA #2, who was first to respond outside, to get Nurse #1 while she remained with him/her. The Statement indicated 911 was called and Resident #1 was transported to the Hospital ED. During an interview on 3/14/23 at 1:31 P.M., Nurse #2 said that she heard a door alarm sounding while she was in a resident's room and said she went to the nurse's station and shut the alarm off. Nurse #2 said she questioned why the alarm went off and quickly looked at the cameras monitors but did not see anyone exit out a door and said that she was not surprised because the alarm had been sounding for at least five minutes before she shut it off. Nurse #2 said the alarm keypad at the nurses's station shows what exit door was opened and said that she could not remember what door had been opened. Nurse #2 said she knew what the process was when an exit door is opened and the alarm goes off, that staff should investigate why an alarm went off and all residents are accounted for and safe and said that she did not follow the process. Nurse #2 said she received a phone call a few minutes later from neighbors that lived behind the Facility that told her that they were hearing someone yelling for help outside. Nurse #2 said she told CNA #2 to watch the cameras monitors and she immediately ran outside to check the perimeter of the building and found Resident #1 outside lying face down below a cement staircase on the side of the building and he/she had a large hematoma above his/her left eye. Nurse #2 said that CNA #2 came running outside and she told her to go call 911 and to go get Nurse #1. Nurse #2 said the EMT's arrived and quickly assessed Resident #1 and he/she was transported to the Hospital Emergency Department (ED). Review of Resident #1's Hospital Emergency Department Report, dated 2/23/23, indicated that Resident #1 was seen in the Emergency Department after being found outside the Facility at the bottom of concrete stairs, was status post fall with a hematoma and abrasions to the left side of his/her forehead. The Report indicated that Resident #1 sustained a closed head injury, left supraorbital (above the eye) hematoma and a nondisplaced fracture through his/her left seventh rib. Review of a Nurse Progress Notes, dated 2/24/23 at, indicated the following: -Resident #1 returned to the Facility with a closed head injury and a fractured rib -contusion over his/her left orbital and swelling/bruising noted with decreased Range of Motion (ROM) on his/her left ring and middle finger During an interview on 3/08/23 at 3:59 P.M. and 3/14/23 at 12:21 P.M., the Director of Nurses (DON) said on 2/23/23, Resident #1 got out of the building through an exit door, and he/she was found outside lying on the ground near cement stairs on the side of the building and said he/she sustained rib fractures and a hematoma above his/her left eye. The DON said that Resident #1 wandered the unit and would state he/she wanted to go home. The DON said when Resident #1's behaviors escalated he/she would start yelling and try to find a way out and said that staff needed to supervise him/her because he/she was an elopement risk. The DON said that during her investigation staff told her they had heard a door alarm sound, but they did not witness Resident #1 going out of the building and said that she could not determine what door he/she had exited from. The DON said her expectation is staff would follow the policy and process when a door alarm sounds.

Based on observations, interviews, and record review, the facility failed to ensure three Residents (#43, #34, and #22), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #43, to implement treatments as ordered to a pressure injury of the left ischium (forms the lower and back region of the hip bone) that became an infected stage 4 pressure injury, and worsening bilateral heel pressure injuries; 2. For Resident #34, to ensure monitoring and pressure related interventions were consistently implemented to prevent the development of a pressure injury to the Resident's bilateral heels; and 3. For Resident #22 to ensure interventions were implemented to maintain skin integrity of a contracted hand. Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, indicated the following: -the nursing staff and physician will assess and document an individual's significant risk factors for developing pressure sores -the nurse shall describe and document the following: full assessment including location, stage, length, width, depth and presence of exudates or necrotic tissue; current treatments including support surfaces 1. Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 1/10/23, indicated Resident #43 needed extensive assist from one person for bed mobility and was dependent upon two staff for transferring between surfaces. Review of the medical record for Resident #43 indicated the following pressure injuries developed during the Resident's stay: A. Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) of the left ischium, B1. Stage 3 pressure injury (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) of the right heel, and B2. Stage 4 pressure injury of the left heel. A. Review of the nursing progress notes indicated on 11/20/22 Resident #43 had developed a pressure injury to the left buttock (ischium) with a darkened center; a new order was implemented for normal saline wash, pat dry, followed by a dry protective dressing and to change daily and as needed. Review of the Weekly Skin Assessment, dated as occurring on 11/17/22 and recorded on 11/20/22, indicated there was a pressure injury to the left lower buttocks, with no measurements or additional information. During an interview on 2/22/23 at 2:40 P.M., the Assistant Director of Nurses said when a new pressure injury develops an incident report is initiated. The surveyor requested the incident report for the pressure injury to the left ischium. On 2/23/23 at 3:05 P.M., the Director of Nurses provided an incident report which indicated a pressure injury developed to the left buttocks (ischium) on 11/20/22. The incident report did not include any measurements or descriptions. The incident report was signed as completed on 2/23/23. During an interview at this time, the Director of Nurses said the agency nurse had never completed an incident report for the wound and she was unable to find any wound descriptions in the medical record. Review of the November 2022 Treatment Administration Record (TAR) indicated the treatment of normal saline wash, pat dry, followed by dry protective dressing was implemented on 11/20/22. The TAR indicated the following descriptions: 11/27/22: wound has slough (necrotic (dead) skin tissue that is green, yellow, tan, or brown, and may be moist, loose, or stringy) 11/28/22: wound change not completed 11/29/22: left buttocks (no further information regarding the wound was documented) 11/30/22: lower left buttock (no further information regarding the wound was documented) Review of the nursing progress notes from 11/20/22 through 12/1/22 failed to indicate any description or change in the wound to the left ischium. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/1/22, indicated the pressure injury to the left ischium was unstageable due to necrosis (dead tissue), measured 5 centimeters (cm) in length by 2.5 cm in width by a non-measurable depth. The wound had a moderate serous exudate (watery drainage), 80% thick adherent devitalized necrotic tissue and 20% skin. The wound physician recommended a treatment of Santyl ointment (used for wound healing), Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement) and cover with a gauze island with border dressing. Review of the December 2022 TAR indicated the treatment of normal saline wash, pat dry, followed by a dry protective dressing was discontinued on 12/2/22. Review of the December 2022 TAR failed to indicate the new recommendation of Santyl, Calcium Alginate, cover with a gauze island with border dressing was implemented. The TAR indicated no treatment was provided to the pressure injury of the left ischium for 19 days (12/2/22 through 12/21/22). Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/15/22 indicated the pressure injury to the left ischium was a stage 4, measuring 4.5 cm in length by 2.5 cm in width by 2 cm in depth, with 60% slough and no change in the wound progress. The recommendation was to continue the treatment of Santyl, Calcium Alginate, and cover with a gauze island with border dressing. Review of a nursing progress note for Resident #43, dated 12/15/22, indicated the buttock wound (pressure injury to the ischium) appeared to be worsening and did not indicate what treatment was being provided. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/22/22, indicated the pressure injury to the left ischium was a stage 4, measuring 4.5 cm in length by 2 cm in width by 4 cm in depth, with 40% slough and no change in the wound progress. The wound consultant indicated a treatment plan to add crushed Flagyl (antibiotic) 500 milligrams (mg) into the wound, continue Santyl, continue Calcium Alginate, continue to use the gauze island with border dressing. Review of the medical record indicated an order was written to obtain a wound culture of the left ischium pressure injury. A specimen was collected on 12/23/22 and results returned on 12/25/22 indicating abnormal results of a moderate growth of bacteria (Proteus Mirabilis). During an interview on 02/23/23 at 1:02 P.M., the Assistant Director of Nurses said she had reviewed the medical record of Resident #43 and found the physician order for the treatment to the left ischium from 12/2/22 was not entered correctly and was not put on the administration records and the nurses do not know to do the treatments if the orders were not entered correctly. She said there was no documentation to indicate any wound treatment was provided to the stage 4 pressure injury to the left ischium from 12/2/22 through 12/21/22 (19 days). Review of the December Medication and Treatment Administration Records and the 12/29/22 Wound Evaluation and Management Summary from the wound consultant indicated the Flagyl to the wound bed was discontinued on 12/29/22. Review of the nursing progress notes indicated a new order was written to obtain a wound culture of the left ischium on 12/31/22. Review of the laboratory results collected on 12/31/22 and reported on 1/4/23 indicated abnormal results of a moderate growth of bacteria (Proteus Mirabilis). The laboratory paperwork indicated an order from the Nurse Practitioner for Bactrim DS (antibiotic) twice per day for 7 days. Review of the telephone orders and Medication Administration Record indicated the order was written for Bactrim DS one tablet once daily for 7 days. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/5/23 indicated the left ischium wound had deteriorated with 30% necrotic tissue and an odor. The recommendation was to add crushed Flagyl 500 mg, continue Santyl, continue Alginate Calcium, and continue gauze island with border. Review of the January 2023 Administration Records failed to indicate the Flagyl was re-ordered on 1/5/23 per the recommendations. During an interview on 2/23/23 at 11:09 A.M., the Assistant Director of Nurses said the Flagyl had not been ordered on 1/5/23 and would have needed a separate order from the wound treatment in order for the pharmacy to send the medication. She said she was not sure how this was missed. During a review of the Wound Evaluation and Management Summaries, dated 1/17/23 and 1/19/23, the Assistant Director of Nurses said the wound consultant thought the Flagyl had been in place from 1/5/23 through 1/19/23 when it was recommended to discontinue the Flagyl. Review of the nursing progress notes indicated on 2/6/23 the primary physician ordered a Foley catheter placement due to the wound on the left buttocks (ischium). The nursing progress note on 2/6/23 at 2:45 P.M. indicated Foley catheter supplies had not been brought upstairs for the catheter to be inserted. There were no further nursing progress notes regarding the Foley catheter. Review of the Administration record indicated the Foley catheter was not inserted and the order was extended until 2/7/23. During an interview on 2/22/23 at 10:18 A.M., the Health Care Proxy said Resident #43 had a wound to the buttock (ischium) and she had been told the facility staff had attempted to put in a Foley catheter and when they were unable to put it in the Assistant Director of Nurses said she would try herself. She said she was assuming Resident #43 had a Foley catheter at this time (two weeks later). During an interview on 2/22/23 at 2:40 P.M., the Assistant Director of Nurses said she did not attempt to put the Foley catheter in Resident #43, and she was unsure why the order was discontinued. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said she had tried to insert the Foley catheter for Resident #43 but was unable to. She said there was no documentation to indicate the physician was aware to re-evaluate the interventions. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/9/23, indicated the wound measured 7 cm in length by 2 cm in width by 5 cm in depth with 20% necrotic tissue, 40% slough with a recommendation to start Flagyl 500 mg crushed to wound bed, continue Alginate Calcium, Collagen Sheet with silver, and Santyl, cover with gauze island with border. Review of the medical record indicated the last wound visit from the wound consultant was conducted on 2/9/23. During an interview on 2/23/23 at 11:09 A.M., the Assistant Director of Nurses reviewed the medical record and said there were no wound measurements or descriptions of the wound since the last wound consultant visit (two weeks prior). She said the expectation is that if the wound consultant is unable to visit the facility the nurses are responsible for evaluating the wound to update the physicians on any changes. B. Review of the medical record for Resident #43 indicated on 10/21/22 the Resident had developed a Deep Tissue Injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the bilateral heels with a new order to elevate the heels while in bed. Review of the Initial Wound Evaluation and Management Summary, from the wound consultant on 10/27/22, indicated the following areas: B1: unstageable DTI of the right heel with intact skin, measuring 2 cm in length by 3 cm in width by non-measurable depth. B2: unstageable DTI of the left heel with intact skin, measuring 2 cm in length by 2 cm in width by non-measurable depth. The recommendation for both heels was to apply skin prep and cover with gauze island with border, off-load (distribute the load to other areas which are not susceptible to pressure) the wounds and float the heels while in bed. Review of the nursing progress note indicated on 10/30/22 the Assistant Director of Nurses noted new recommendations from the wound consultant and new treatments were ordered. Review of the October and November 2022 Treatment Administration Records (TAR) for Resident #43 indicated an order was implemented from 10/20/22 through 11/20/22 to wash bilateral heels with normal saline, pat dry, apply Puracol (a highly absorbent dressing) and cover with a foam dressing. During an interview on 2/23/23 at 9:30 A.M., the Assistant Director of Nurses said she could not tell why the treatment that was ordered was different from the one recommended by the wound consultant. Review of the nursing progress notes for Resident #43 indicated on 11/8/22 bilateral heel dressings were changed with a moderate amount of yellow, foul-smelling drainage noted on the old dressing. Review of the nursing progress notes, dated 11/9/22, indicated both heels were open with a large amount of foul-smelling drainage on the old dressing. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 11/10/22 indicated the following: B1: unstageable DTI of the right heel measuring 3 cm in length by 3 cm in width by unmeasurable depth with light serous drainage B2: unstageable DTI of the left heel measuring 3.5 cm in length by 3 cm in width by unmeasurable depth with light serous drainage The recommendation for both heels was to discontinue the skin prep, start collagen sheet with silver (a sheet that maintains a moist environment at the wound surface to aid in the formation of healthy tissue, the silver is intended to reduce bacteria in the wound) and apply the gauze island with border. Review of the November TAR indicated the following treatments initiated on 11/11/22: B1. wash DTI of right heel with normal saline, pat dry, apply collagen sheet, cut to fit, cover with foam dressing B2. wash DTI of left heel with normal saline, pat dry, apply collagen sheet, cut to fit, cover with foam dressing. Neither order contained the recommended collagen sheet with silver. During an interview on 2/23/23 at 9:30 A.M., the Assistant Director of Nurses said the order on 11/11/22 should have been written for collagen sheet with silver and these were not the same treatments. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 11/17/22, indicated the following: B1: Stage 3 pressure injury to the right heel measuring 3 cm in length by 3 cm in width by unmeasurable depth with moderate serous drainage, and 30% necrotic tissue. The wound progress was noted as deteriorated. B2: Stage 3 pressure injury to the left heel measuring 4 cm in length by 3 cm in width by an unmeasurable depth with moderate serosanguinous (fluid with blood) drainage and odor and 20% necrotic tissue. The wound progress was noted as deteriorated. The recommendation for both heels was to discontinue the collagen sheet with silver, add Santyl, add Calcium Alginate, add ABD pad, gauze roll, tape, and a gauze island with border dressing. Review of the December 2022 TAR for Resident #43 indicated the following: B1: right heel treatment not completed on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/20 B2: left heel treatment not completed on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/20 Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/26/23, indicated the following: B1: stage 3 pressure injury to the right heel measuring 3 cm in length by 2 cm in width and an unmeasurable depth (surface area 6.0 cm); showing improvement. Treatment recommendation was to continue Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll and tape. B2: stage 4 pressure injury to the left heel measuring 3 cm in length by 4 cm in width and an unmeasurable depth, unchanged status. Treatment recommendation was to add Santyl, continue Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll, and tape. Review of the January 2023 TAR for Resident #43 indicated the following on 1/27/23: B1: the treatment to the right heel, which was to continue per the recommendations on 1/26/23 was discontinued, no further treatments to the right heel were ordered at that time. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/2/23, indicated the following: B1: stage 3 pressure injury to the right heel measuring 3.5 cm length by 3.5 cm in width and an unmeasurable depth (surface area 12.25 cm) with a recommendation to continue the previous order of Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll and tape. Review of the February 2023 TAR for Resident #43 indicated the treatment to the right heel was re-instated on 2/6/23 with 10 days of missed treatments to the right heel. During an interview on 2/23/23 at 12:08 P.M., the Assistant Director of Nurses said the order for the right heel was discontinued in error and the treatment should have continued through the days it was missed. Review of all Wound Evaluation and Management Summaries from 11/28/22 through 2/9/23 recommend the Prevalon boots (have a cushioned bottom that floats the heel off the surface, helping to reduce pressure) with the heel cut out. On 2/21/23 at 8:50 A.M., the surveyor observed Resident #43 to be seated in a Geri-Chair (reclining wheelchair), wearing blue booties to the bilateral feet. The blue booties were not observed to have a heel cut out. On 2/22/23 at 10:52 A.M., the surveyor observed the Resident in the Geri-Chair with blue booties, neither bootie had heel cut outs. On 2/23/23 at 8:03 A.M., the surveyor observed the Resident in the Geri-Chair with blue booties which did not have a heel cut out. During an interview on 2/23/23 at 12:08 P.M., the Assistant Director of Nurses said she had not seen the recommendation from the wound physician regarding the Prevalon boots with heel cut out as she had not read that section of the wound evaluation. She said no one at the facility had ordered the correct booties for the Resident. The surveyor attempted to contact the primary physician of Resident #43 on 2/23/23 at 11:46 A.M., with no return call. The surveyor contacted the answering service for the Medical Director on 2/23/23 at 2:02 P.M. and requested a call back, with no return call. 42742 2. Resident #34 was admitted to the facility in March 2022 with diagnoses including unspecified severe protein-calorie malnutrition and encounter for palliative care. Review of the Minimum Data Set (MDS) assessment, dated 12/15/22, indicated that Resident #34 was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The MDS also indicated the Resident was at risk for developing pressure ulcers. Review of current Physician's Orders indicated the following: -Off-load (distribute the load to other areas which are not susceptible to pressure) bilateral heels with pillow (8/17/22) -Weekly skin checks on bath day, complete under Matrix observation and notify MD/NP of new or worsening skin areas and document in progress note (3/10/22) Review of the Pressure Ulcer Care Plan, initiated 3/15/22, indicated the following: Problem: -Resident is at risk for pressure ulcers related to incontinence and dependence on staff for bed mobility and peri-hygiene Goal: -Resident's skin will remain intact Approach/Interventions: -off-load heels as tolerated -report any signs of skin breakdown (sore, tender, red, or broken areas) On 2/22/23 at 8:27 A.M., the surveyor observed Resident #34 sitting up in bed with his/her heels resting on the mattress and not off-loaded per physician's orders. During an interview on 2/23/23 at 10:36 A.M., the Director of Nursing (DON) said the expectation was for staff to implement interventions per physician's orders. Review of a nursing progress note, dated 1/30/23, indicated a new, small open area on the right great toe. Review of the medical record failed to indicate consecutive weekly Skin Assessments had been completed under the Matrix observation, per physician's order, since staff first identified the open area on 1/30/23 for continued monitoring. During an observation with interview on 2/23/23 at 11:55 A.M., the surveyor and DON assessed the Resident's feet for pressure areas. The Resident's heels were observed resting on the mattress and not off-loaded per physician's orders. A bed cradle (frame at the foot of the bed to keep sheets/blankets off legs/feet) was in place; however, blankets were observed resting on top of the Resident's feet and not over the cradle. The DON said the heels were pink but they were like that and should have been off-loaded to prevent further injury, and the blankets should not have been resting on top of the Resident's feet. Review of the medical record failed to indicate staff had reported any recent signs of skin breakdown on the Resident's heels as the DON had indicated during the assessment with the surveyor. During an interview on 2/23/23 at 2:02 P.M., the surveyor reviewed the weekly skin assessments with the DON who said they were not being consistently done. She said the expectation was for staff to complete them weekly as ordered. The DON said she did not document her earlier assessment of the Resident's heels. On 2/23/23 at 7:07 A.M., the surveyor observed Resident #34 lying in bed sleeping. His/her heels were not off-loaded in the bed. During an interview on 2/23/23 at 8:06 A.M., Nurse #6 said Resident #34 was on Hospice care and was supposed to have his/her heels elevated and the bed cradle in place. She said staff were expected to implement interventions to prevent new areas from developing. 34145 3. Resident #22 was admitted to the facility in July 2019 with diagnoses including Alzheimer's dementia and contracture of the right and left shoulder. Review of the 12/15/22 Minimum Data Set (MDS) assessment indicated Resident #22 had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living and had impaired functional limitation in range of motion in both upper and lower extremities. Review of the medical record indicated the following Physician's Orders: -Bilateral palmar guards on during the daytime hours-after morning care-assess skin integrity (5/24/21) -Bilateral palmar guards to be removed with evening care-assess skin integrity on removal (5/24/21) -Occupational Therapy (OT) evaluation and treatment as indicated (12/8/22) Review of comprehensive care plans included but was not limited to: -Problem: Resident is at risk for complications related to the use of bilateral upper extremity palmar guards (9/16/21) -Approach: Assess for pain; doff (take off) bilateral palmar guards as per instructions from registered Occupational Therapist (prior to evening care); don (put on) bilateral palmar guards as per instructions from registered Occupational Therapist (after morning care); may remove palmar guards for hand hygiene; skilled Occupational Therapist to provide education to insure the staff understand placement of palmar guards and wear time; staff to observe for signs/symptoms of skin breakdown or any signs/symptoms of infection including redness/discoloration, odor, swelling, blisters, fluid, sores, pimples, skin lesions, or any non-removable foreign material (9/25/22) -Goal: Resident will utilize bilateral upper extremity palmar guards to decrease pain and for contracture prevention and will not develop any complications related to their use. On 2/21/23 at 10:16 A.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room with a palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted, and resting on his/her lap. On 2/22/23 at 8:28 A.M., the surveyor observed Resident #22 seated in a wheelchair in the Visitor's Lounge sleeping. The Resident had no palmar guards in place in either the left or right hand. The Resident's hands were contracted and resting in his/her lap. On 2/22/23 at 8:35 A.M., the surveyor observed Resident #22 seated in a wheelchair being fed breakfast in the unit's Visitor Lounge. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted, and resting on his/her lap. During an interview on 2/22/23 at 9:13 A.M., Nurse #5 said Resident #22 is supposed to have bilateral palmar guards in place, but it has been missing for a few weeks. Review of 1/30/23 and 2/1/23 Nursing Notes indicated Resident #22's left palmar guard was missing. During an interview on 2/22/23 at 1:05 P.M., Rehab Staff #2 said she works per diem and last worked with Resident #22 a few weeks ago. She said the Resident has used the palmar guards for a long time. She said they were replaced on 1/4/23 because they were worn. She said she was not aware of the missing palmar guard and wished she knew earlier so she could have replaced it immediately. On 2/22/23 at 1:21 P.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room. The Resident had no palmar guards applied to either the left or right hand. His/her hands were contracted and resting in his/her lap. The right palmar guard was observed placed on a bureau. During an interview on 2/22/23 at 2:15 P.M., Rehab Staff #1 said she was not aware Resident #22's left palmar guard was missing and staff was not applying the guards daily as ordered. She said the purpose of the palmar guards was to prevent further contracture and maintain skin integrity. On 2/23/23 at 8:27 A.M. and 10:39 A.M., the surveyor observed Resident #22 seated in a wheelchair in the dayroom. A palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted and resting on his/her lap. On 2/23/23 at 11:40 A.M., Rehab Staff #2 was observed seated next to Resident #22. She said she conducted a screen yesterday and was currently conducting an evaluation of Resident #22's right and left-hand contractures. She said when she arrived, the Resident had a palmar guard in his/her right hand, but nothing in his/her left hand. Rehab Staff #2 said the Resident has skin breakdown on the palm of his/her left hand and redness on the palm of his/her right hand. She said it could have been avoided if the palmar guards were applied as ordered. Review of the completed 2/23/23 OT Evaluation and Plan of Treatment included, but was not limited to: -Upon arrival, resident presented with palm protector splint in right hand and no splint or hand roll in left. Facecloth was obtained and placed in left palm until facility left palm protector arrives to facility. Right palm red hardened area, and left palm open areas were noted. -It is recommended the resident wear a palmar guard on the right and left hand at all times except bathing, exercise, and at night, in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further risk of contractures.

Based on interview, policy review, and record review, the facility failed to notify the Resident's physician about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#43), from a total sample of 17 residents. Specifically, the facility failed to notify the primary physician of: a. a change in a new pressure injury in order to alter the treatment plan to prevent deterioration, and b. a significant weight loss of over 9% in 7 weeks in order to alter the plan of care to prevent an additional weight loss of 4.96%. Findings include: Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia and hypertension. a. Review of the nursing progress notes indicated on 11/20/22 Resident #43 had developed an area to the left buttock with a darkened center. A new order was implemented for normal saline wash, pat dry, followed by a dry protective dressing and to change the dressing daily and as needed. Review of the Weekly Skin Assessment, dated as occurring on 11/17/22 and recorded on 11/20/22, indicated there was a pressure ulcer to the left lower buttocks, with no measurements or additional descriptive information. Review of the November 2022 Treatment Administration Record (TAR) indicated the treatment of normal saline wash, pat dry, followed by a dry protective dressing was implemented on 11/20/22. The TAR indicated the following description on 11/27/22: wound has slough (necrotic (dead) tissue that is green, yellow, tan, or brown, and may be moist, loose, or stringy). Review of the medical record for Resident #43 failed to indicate the primary physician had been notified of the change in condition of the wound from an area with a darkened center to slough on 11/27/22 following the treatment of the wound. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/1/22 indicated the area to the left ischium was unstageable due to necrosis, measured 5 centimeters (cm) in length by 2.5 cm in width by a non-measurable depth. The wound had a moderate serous exudate (watery drainage), 80% thick adherent devitalized necrotic tissue and 20% skin. The wound physician recommended a treatment of Santyl, Calcium Alginate and cover with a gauze island with border dressing. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said the physician was notified when the area developed on 11/20/22 as they had ordered the dry protective dressing. She said she could not locate any documentation to indicate the primary physician had been alerted to changes in the wound which could alter the treatment based on the wound becoming necrotic. b. Review of the facility's policy titled Weight Measurement, revised in February 2022, indicated the charge nurse will notify the physician, responsible party, and dietitian when a 5% more or less variance is noted. Review of the medical record for Resident #43 indicated the following weights: 11/3/22: 132.1 pounds (lbs.) 12/23/22: 119.0 lbs. (a loss of 9.92% in 7 weeks) 1/5/23: 120.2 lbs. (a loss of 9.02% in two months) 1/19/23: 113.1 lbs. (an additional loss of 4.96% in two weeks, for a total loss of 14.38% in less than three months) Review of the medical record for Resident #43 (including telephone orders, progress notes, and care plans) failed to indicate the physician was notified of the significant weight loss on 12/23/22 and failed to indicate any changes to the plan of care between 12/23/22 and 1/6/23. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said she was unable to locate any documentation or recommendations to indicate the physician had been notified of the significant weight loss of 9.92% when it first occurred on 12/23/22.

Based on observation, record review, and interview, the facility failed to ensure interventions were implemented for the treatment of bilateral hand contractures for one Resident (#22) out of a sample of 17 residents. Specifically, the facility failed to ensure bilateral palmar guards were in place as ordered by the physician to maintain and prevent further contracture and increased pain with range of motion. Findings include: Resident #22 was admitted to the facility in July 2019 with diagnoses including Alzheimer's dementia and contracture of the right and left shoulder. Review of the 12/15/22 Minimum Data Set (MDS) assessment indicated Resident #22 had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living and had impaired functional limitation in range of motion in both upper and lower extremities. Review of the medical record indicated the following Physician's Orders: -Bilateral palmar guards on during the daytime hours-after morning care-assess skin integrity (5/24/21) -Bilateral palmar guards to be removed with evening care-assess skin integrity on removal (5/24/21) -Occupational Therapy (OT) evaluation and treatment as indicated (12/8/22) Review of comprehensive care plans included but was not limited to: -Problem: Resident is at risk for complications related to the use of bilateral upper extremity palmar guards (9/16/21) -Approach: Assess for pain; doff (take off) bilateral palmar guards as per instructions from registered Occupational Therapist (prior to evening care); don (put on) bilateral palmar guards as per instructions from registered Occupational Therapist (after morning care); may remove palmar guards for hand hygiene; skilled Occupational Therapist to provide education to insure the staff understand placement of palmar guards and wear time; staff to observe for signs/symptoms of skin breakdown or any signs/symptoms of infection including redness/discoloration, odor, swelling, blisters, fluid, sores, pimples, skin lesions, or any non-removable foreign material (9/25/22) -Goal: Resident will utilize bilateral upper extremity palmar guards to decrease pain and for contracture prevention and will not develop any complications related to their use. Review of a 12/8/22 OT Evaluation & Plan of Treatment note indicated Resident #22 was evaluated for decreased hand function below functional baseline and demonstrates right hand pain intensity of 5/10 as evidenced by facial grimacing. Goals of treatment identified included, but were not limited to: -Decrease right hand pain from 5/10 utilizing Pain Assessment in Advanced Dementia scale (PAINAD) to 3/10 during passive range of motion; -Resident will safely wear least restrictive splinting/orthotic device during daily tasks without complaints of discomfort in order to improve passive range of motion for adequate hygiene. The Resident was discharged from OT services on 1/27/23 and noted a pain level of 4/10 on the PAINAD scale. Review of 1/30/23 and 2/1/23 Nursing Notes indicated Resident #22's left palmar guard was missing and a towel was placed in the Resident's left palm. The Nurse indicated the Rehab department was notified of the missing palmar guard. On 2/21/23 at 10:16 A.M., the surveyor observed Resident #22 in a high back wheelchair in his/her room. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand was contracted and resting on his/her lap. There was no devices or towel in place in the Resident's left hand. On 2/22/23 at 8:28 A.M., the surveyor observed Resident #22 seated in a high back wheelchair in the Visitor's Lounge sleeping. The Resident had no palmar guards applied to either the left or right hand and his/her hands were contracted and resting in his/her lap. On 2/22/23 at 8:35 A.M., the surveyor observed Resident #22 seated in a high back wheelchair being fed breakfast in the unit's Visitor Lounge. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand was contracted and resting on his/her lap. There was no devices or towel in place in the Resident's left hand. During an interview on 2/22/23 at 9:13 A.M., Nurse #5 said Resident #22 was supposed to have bilateral palmar guards in place but does not have the left guard in place right now. She said the left guard was missing and they were waiting on therapy for a new one. During an interview on 2/22/23 at 1:05 P.M., Rehab Staff #2 said she works per diem and last worked with Resident #22 a few weeks ago. She said the Resident has had the palmar guards for a long time and were replaced on 1/4/23 because they were worn. She said she was not aware of the missing palmar guard and wished she knew earlier so she could have replaced it immediately. She said she was going to perform a Rehab screen for Resident #22 today. On 2/22/23 at 1:21 P.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room. The Resident had no palmar guards applied to either the left or right hand and his/her hands were contracted and resting in his/her lap. The right palmar guard was observed on the bureau. During an interview on 2/23/23 at 11:40 A.M., Rehab Staff #2 said she conducted a screen yesterday and was currently conducting an evaluation of Resident #22's right and left hand contractures. She said when she arrived, the Resident had a palmar guard in his/her right hand, but nothing in his/her left hand. She said the Resident demonstrated increased pain when she attempted passive range of motion of his/her left hand, and it could have been avoided if the palmar guards were applied as ordered. She said she would pick up the Resident for services due to the decline. Rehab Staff #2 said she had ordered another palmar guard and expects it to come in tonight. Review of the completed 2/22/23 Rehabilitation Screen Form and the 2/23/23 OT Evaluation and Plan of Treatment included, but was not limited to: -Resident #22 experienced an increase in pain 6/10 (pain level on 1/27/23 was 4/10) when attempted left hand and digit passive range of motion; -Resident would benefit from skilled OT services to decrease pain and prevent further contractures; -Bilateral palm protector splints have not been properly utilized for 3+ weeks; -Resident would benefit from skilled services in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further risk of contractures; -It is recommended the Resident wear a palmar guard on the right and left hands at all times except bathing, exercise, and at night, in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further contractures. During an interview on 2/23/23 at 1:47 P.M., the Assistant Director of Nursing (ADON) said staff should have notified the Rehab department immediately that Resident #22's left palmar guard was missing to prevent the Resident from experiencing increased pain during range of motion and further contracture.

Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for Resident #43 with an unplanned, significant weight loss, out of a total sample of 17 residents. Specifically, the facility failed to implement nutritional interventions to prevent further weight loss. Findings include: Review of the facility's policy titled Weight Measurement, revised in February 2022, indicated the frequency of weights will be determined by the interdisciplinary team (IDT) based on the resident's individual needs. When a significant weight fluctuation of 5% more or less is noted, the resident will be weighed based on the determination of the IDT. The resident's plan of care will be updated accordingly. Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia. Review of the medical record failed to include a care plan to indicate the nutritional goals and interventions for Resident #43. Review of the medical record indicated the following weights: 11/3/22: 132.1 pounds (lbs.) 12/23/22: 119.0 lbs. (a loss of 9.92% in 7 weeks) 1/5/23: 120.2 lbs. (a loss of 9.02% in two months) 1/19/23: 113.1 lbs. (an additional loss of 4.96% in two weeks, for a total loss of 14.38% in less than three months) Review of the medical record (including telephone orders, progress notes, and care plans) failed to indicate any changes to the plan of care between 12/23/22 and 1/6/23. Review of a progress note by the Registered Dietitian on 1/6/23 (14 days after the significant weight loss) included: -laboratory values and skin concerns with the Resident having an approximate total intake of 815 kcal (kilocalories) and an estimated need of 1912 kcals. -Plan to increase the nutritional frozen treat (Magic Cup) to twice per day for an additional 600 kcal for a total intake with interventions of 1415 kcals. -Continue to monitor weights. The progress note failed to mention the significant weight loss from 132.1 lbs. to 119.0 lbs (a loss of 9.92%), failed to address interventions to attain the estimated need of 1912 kcals, and failed to indicate how often weights were to be obtained. Review of the medical record indicated Magic Cup, twice per day was ordered on 1/9/23. Review of the progress note by the Registered Dietitian on 1/23/23, a quarterly review note, indicated: -The Resident triggered for a significant weight loss of 5% in 30 days with a weight of 113.1 lbs. on 1/19/23. -The Resident had an approximate total intake of 1415 kcals with an estimated need of 1912 kcals and that intake is insufficient to meet needs, putting the Resident at risk for malnutrition related to significant weight loss. -Resident #43 consumed an average of 38% of meals. -The Registered Dietitian recommended to increase the Magic Cup to three times per day and that an appetite stimulant may benefit the Resident. -Plan to continue to monitor intakes and weights. The Registered Dietitian failed to indicate the significant weight loss of 14.38% in less than three months, failed to address interventions to attain the estimated need of 1912 kcals as the increased Magic Cup would bring the approximate total intake to 1715 kcal, almost 200 kcal below the estimated need, and failed to indicate how often weights would be monitored. Review of the Physician's Orders following the Registered Dietitian review on 1/23/23, indicated the Magic Cup was increased to three times per day. Review of the medical record indicated as of 2/21/23 Resident #43 had not had their weight monitored since 1/19/23, four weeks prior. On 2/21/23 at 11:00 A.M., the surveyor observed a handwritten note at the unit nursing station indicating the family of Resident #43 would like to have the Resident fed at every meal. On 2/21/23 at 12:35 P.M., the surveyor observed Resident #43 to be in his/her room in a reclining wheelchair with an overbed table with their lunch meal on it. The meal tray contained a cup of juice, which had been knocked over and spilled on the meal tray. There was a half of peanut butter and jelly sandwich, which was half eaten, sausage chopped up in a roll, uneaten, cabbage uneaten and a chocolate Magic Cup, uneaten. There were no staff members in the room with the Resident. At 12:50 P.M., the surveyor observed Certified Nursing Assistant (CNA) #3 take the tray from Resident #43. During an interview at this time, the CNA said she did not know who helped the Resident eat, but that the Resident does not eat a lot of food. At this time two additional CNAs approached the surveyor and CNA #3. CNA #5 said she did not have Resident #43 on her assignment and did not help him/her eat. CNA #4 said she did not help the Resident eat but knew there was a note from the family indicating that someone needed to help the Resident eat. On 2/22/23 at 8:15 A.M., the surveyor observed Resident #43 with their breakfast tray including orange juice, eggs, a biscuit, coffee, oatmeal and a half of peanut butter and jelly on a small plate. There was no Magic Cup on the breakfast tray. Review of the meal ticket failed to indicate a Magic Cup should have been included. Resident #43 was observed to be able to pick up the peanut butter and jelly sandwich. At 8:28 A.M. the surveyor observed CNA #5 ask Resident #43 if they were all set and take the Resident's meal tray. Approximately 25% of the food had been eaten. During an interview on 2/22/23 at 10:18 A.M., the Health Care Proxy of Resident #43 said the Resident had a family member who came every day and wanted the Resident to have help with eating. The Health Care Proxy said Resident #43 was having difficulty eating due to their medical condition and she had spoken with one of the nurses the week prior and asked them to help the Resident eat because he/she was not eating enough. During an interview with observation on 2/23/23 at 8:22 A.M., CNA #10 said she likes to feed Resident #43 things that may be difficult, such as the oatmeal she was feeding now. She said the Resident can pick up his/her own sandwich but eats more of other items if someone helps him/her. The surveyor observed the breakfast tray to not have a Magic Cup. During an interview on 2/22/23 at 4:36 P.M., the Director of Nurses said she had placed a call to the Dietitian to see how often Resident #43 should be weighed. She said they had talked about it as an Interdisciplinary Team (IDT), but she did not know how often the Resident was to be weighed. Review of the medical record failed to indicate how often the weight of Resident #43 should be monitored and failed to indicate a plan established by the IDT for weight monitoring. During an interview on 2/23/23 at 8:24 A.M., the Director of Nurses said the weight for Resident #43 on 2/22/23 (four weeks after the last significant weight loss) was now 106.5 lbs. (a loss of 5.84% in one month, a loss of 10.5% in three months and a total loss of 19.38% in less than four months). During an interview on 2/23/23 at 12:10 P.M., the Director of Nurses said the Magic Cup should have been on the meal tray for every meal and should have been on the meal ticket for Resident #43. The DON reviewed the physician's order for Magic Cup with the surveyor and said the order was written as three times per day but entered incorrectly as a frequency of twice per day. The DON said the IDT should have had a plan following the initial significant weight loss. The surveyor attempted to contact the Registered Dietitian on 2/23/23 at 11:15 A.M. with no response.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance from staff with bed mobility and transfers and was assessed as being at high risk for falls, the Facility failed to ensure staff maintained his/her safety to prevent an accident. On 2/24/22, Certified Nurse Aide (CNA) #1 in preparation for transferring him/her out of bed, positioned and left Resident #1 seated at the edge of the bed, when CNA #1 then turned away from him/her to bring the wheelchair closer to the bed, Resident #1 fell forward out of bed onto the floor, striking his/her head and sustained a laceration to his/her forehead which required sutures to close. Findings include: Review of the Facility's Policy, titled Falls Management Program, dated as revised September 2020, indicated that the Facility will identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The Policy indicated that interventions are related to a resident's specific risks and causes in an effort to prevent the resident from falling and/or minimize complications from falling. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/03/22, indicated that on 02/24/22 Resident #1 was found lying on the floor on his/her right side, bleeding from a laceration on his/her forehead. The Report indicated that a Certified Nurse Aide (CNA later identified as CNA #1) assisted Resident #1 to a seating position at the side of the bed, CNA #1 turned to pull the wheelchair closer to the bed to transfer Resident #1 and Resident #1 fell forward off the side of the bed. The Report indicated that Resident #1 sustained a laceration to his/her forehead and was transferred the Hospital Emergency Department. The Report indicated that Resident #1 returned from the Hospital Emergency Department with eight sutures to a four centimeter (cm) laceration on his/her forehead. Resident #1 was admitted to the Facility in July 2018, diagnoses included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and disc degeneration of the lumbar region. Review of Resident #1's Fall Risk Assessment, dated 01/15/22, indicated that he/she was at high risk for falls. Review of Resident #1's CNA Care Card, dated 01/22/22, indicated that he/she required the assistance of one staff member with positioning and transfers. Review of Resident #1's Activities of Daily Living (ADL) plan of care, dated 01/26/22, indicated that he/she was dependent on staff for all ADL Care, which included transfers. Review of Resident #1's Significant Change Minimum Data Set (MDS) assessment, dated 1/26/22, indicated he/she had impaired range of motion in both upper extremities (MDS defined as shoulders, elbows, wrists, hands), as well as impaired balance and impaired ability to transfer from surface to surface, that Resident #1 was not steady and was only able to stabilize him/herself with human (physical) assistance. The MDS indicated Resident #1 required an extensive assistance of two staff members to transfers between surfaces, which included being transferred from his/her bed to the wheelchair. Review of a Fall Incident Report, dated 02/24/22 at 10:30 A.M., indicated that Resident #1 was seated at the edge of his/her bed when CNA #1 turned away (from him/her) towards the wheelchair and Resident #1 fell forward onto the floor striking his/her forehead and sustained a laceration. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department for treatment. Review of a Nurse Progress Note, dated 02/24/22, indicated that Resident #1 sustained a witnessed fall with head laceration and was transferred to the Hospital Emergency Department for treatment and evaluation. The Note indicated that Resident #1 returned from the Hospital Emergency Department with eight sutures to his/her forehead. During an interview on 03/29/22 at 12:31 P.M., Nurse #1 said that Resident #1 required extensive assistance from staff for positioning and transfers. Nurse #1 said that Resident #1 was too weak and could not hold him/herself up in a sitting position in bed. Nurse #1 said CNA #1 told her that she sat Resident #1 up on the edge of the bed and that she (CNA #1) turned away from Resident #1 to get the wheelchair closer to the bed. Nurse #1 said CNA #1 should have never left Resident #1 in a sitting position at the edge of the bed and should not have turned away from him/her. Nurse #1 said that CNA #1 should have positioned the wheelchair closer to the bed first and then positioned Resident #1 at the side of the bed, while keeping her eyes and hands on Resident #1 at all times. Review of Certified Nurse Aide (CNA) #1's written witness statement, dated 02/24/22, indicated that she sat Resident #1 up in bed to transfer him/her into the wheelchair, turned her back for a quick second to pull the wheelchair closer to the bed when Resident #1 fell out of bed. During an interview on 03/29/22 at 11:42 A.M., CNA #1 said that she was getting ready to transfer Resident #1 from bed into the wheelchair, said she sat Resident #1 in an upright position on the side of the bed and said she turned away from Resident #1 to pull the wheelchair closer to the bed. CNA #1 said that was when Resident #1 fell forward out of bed onto the floor. CNA #1 said that she did not actually see Resident #1 fall out of bed, said that when she moved the wheelchair closer to the bed, she heard a noise and that is when she saw Resident #1 on the floor. CNA #1 said that Resident #1 landed on his/her head and said he/she was bleeding from his/her head. CNA #1 said she should have left Resident #1 in a lying position in bed while she got the wheelchair closer to the bed and said she should not have sat Resident #1 up in bed or turned away from him/her to get the wheelchair. During an interview on 03/29/22 at 3:10 P.M., the Director of Nurses (DON) said that CNA #1 should not have sat Resident #1 up at the edge of the bed and turn away from him/her. The DON said that Resident #1 was too weak to and could hold his/her upper body up in a seated position, that Resident #1 had no trunk strength. Review of a Hospital Emergency Department Report, dated 02/24/22, indicated that Resident #1 sustained a four cm laceration to his/her forehead that required eight sutures to repair.

Based on observations, interviews and record review the Facility staff failed to ensure for 1 Resident (#17) with limited range of motion and contractures, received the appropriate equipment to prevent further decrease in range of motion, in a total sample of 13 Residents. Findings include: 1. Resident # 17 was admitted to the Facility in 09/2017 with a [DIAGNOSES REDACTED]. Resident #17 was observed throughout the survey process from 01/29/19 through 01/31/19. The Residents' bilateral hands were observed to have fingers folded, clenched to the palms of his/her hands and the Resident was observed to have a wedge cushion between bent knees while out of bed. A review of the quarterly MDS, dated [DATE], in the area of functional limitation for range of motion indicated there was no impairment to the upper extremity (shoulder, elbow, wrist, hand) and there was an impairment on both sides of the lower extremity (hip, knee, ankle, foot). A review of the physician orders [REDACTED].M. and a left hand palmer guard to be applied after breakfast and off at 3:00 P.M. A review of the medical record indicated that Resident #17 was treated by Occupational Therapy (OT) from 09/05/18 until 10/28/18. The medical record indicated an order written [REDACTED]. The OT discharge summary indicated the Resident could tolerate bilateral hand orthotics (palmer guard) for four hours in order to prevent skin breakdown and increased contractures. On 01/29/19 at 11:12 A.M. Resident #17 was observed to be in bed, there were no orthotic devices observed on either hand. On 1/29/19 at 4:00 P.M. the spouse of Resident #17 was interviewed. The spouse said that the Resident was to wear bilateral hand splints, but had not been wearing them on this day. On 01/30/19 at 12:13 P.M. the Resident was observed in a wheelchair in the main dining room. The Resident was not observed to be wearing any hand splints or wearing a left palmer guard. Nurse #2 was interviewed on 1/30/19 at 3:50 P.M. She said that she was the medication nurse for Resident #17 and the treatment nurse would be responsible for checking the hand splints for Resident #17. Nurse #1 was interviewed on 01/31/19 at 10:45 A.M. She said that she was the treatment nurse scheduled the previous day and on this day. She said that she provided treatments to both Unit 2 and Unit 3. She said that she usually starts on Unit 3 and was just starting on treatments for Unit 2 at this time. She reviewed the treatment orders for Resident #2 and confirmed that FYI (for your information) orders were written for bilateral hand splints to be worn from 8:00 A.M. until 2:00 P.M. She had no information regarding a left palmer guard. Nurse #1 said that she was not responsible to ensure that the Resident was wearing the splints at 8:00 A.M. but was only responsible to check to see if the splints were on when she eventually got to the Resident. Nurse #1 said that the Certified Nursing Assistant (CNA) was responsible for ensuring the splints were put on in the morning. She was unable to recall if the Resident was wearing hand splints as indicated on the treatment sheet, the day prior. CNA #1 was interviewed on 01/31/19 at 11:00 A.M. CNA #1 said that on the CNA paperwork there was no indication of the prescribed devices to use for the Resident. The CNA reviewed the paperwork for Resident #17 with the Surveyor. The nursing assistant decubitus prevention sheet indicated to use a pillow between the legs (when in bed), there was no indication to use the knee abductor wedge cushion when up in the wheelchair, no indication of splints, no indication of use of the left palmer guard, and no indication to use lower extremity splints during the afternoon nap. The Surveyor and CNA #1 went to the room of Resident #17 where the Resident was observed to be lying in bed. CNA #1 confirmed there were no devices on the Resident's hands at this time. CNA #1 demonstrated that there were two palmer guards (a soft palm guard with a foam roll) in the Resident's nightstand. She said that she was to place one in the left hand of the Resident and she was not sure why there was another one there. She said that it was difficult to get the palmer guard in to the Resident's left hand as she did not want to force the fingers away from the palm, which could possibly cause pain. She said that these were the only hand devices and did not know anything about bilateral hand splints for Resident #17. On 01/31/19 at 11:32 A.M. the Occupational Therapist was interviewed. The therapist reviewed the discharge summary for OT dated 10/28/18 which indicated Resident #17 was to wear bilateral palmer guards. She said that the order for bilateral hand splints should have been discontinued and updated for the Resident to use the bilateral palmer guards. She said that the Rehabilitation Department was not aware that the CNA was no longer able to apply the left palmer guard due to the contractures. The regional Rehabilitation Director was interviewed on 01/31/19 at 12:00 P.M. She said that there was a telephone physician's orders [REDACTED]. The Occupational Therapist was interviewed again on 01/31/19 at 2:30 P.M. She said that she evaluated Resident #17 and determined that the left hand contracture had worsened and she was unable to open either hand as the Resident was grimacing in pain.