Every finding on record at Garden Place Healthcare

Based on observations and interviews, the facility failed to follow 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 food items were properly dated and stored in the main kitchen and equipment was maintained in a sanitary manner;2. Ensure the ice machine in the main kitchen was maintained in a clean, sanitary condition; and3. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). Findings include:Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.- 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location.- 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues.- 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Food and Supply Storage, dated last revised 6/2018, indicated but was not limited to the following:- Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates.- Follow recommendations from the manufacturer when indicated on the product for storage time and storage location. Review of the facility's policy titled Ice Production and Handling, revised 6/2018, indicated but was not limited to:- Keep equipment clean, including draining, cleaning, and sanitizing internal components of the ice machine as needed and according to the manufacturer's specifications, cleaning schedules and preventative maintenance schedules. 1. On 12/5/25 at 7:45 A.M., the surveyor made the following observations in the main kitchen:- One container of scrambled eggs on the second shelf in the walk-in refrigerator was not labeled/dated.- One Imperial Thickened Dairy Drink (Mildly Thick Nectar Consistency) was opened in the reach-in refrigerator by the service line and did not have an open date. The manufacturer's label indicated to discard seven days after opening.- One Ocean Spray 100% Apple Juice (60 fluid ounces) Bottle was opened and not dated in the reach-in refrigerator.- One clear pitcher with a milk-like substance was not labeled or dated.- One 2-Liter (L) Coca Cola Bottle was located on the bottom shelf of reach-in refrigerator, it was opened and not dated.- The microwave located on a table behind the service food line had dark, black burn-like stains noted to top inside. On 12/9/25 at 11:00 A.M., the surveyor made the following observations in the main kitchen:- Two Imperial Thickened Dairy Drinks (Mildly Thick Nectar Consistency) were opened in the reach-in refrigerator by the service line and did not have an open date. The manufacturer's label indicated to discard seven days after opening.- One clear pitcher with a milk-like substance was not labeled or dated.- The microwave located on a table behind the service food line had dark, black burn-like stains noted to top inside. During an interview on 12/10/25 at 9:00 A.M., the surveyor and the Food Service Director (FSD) toured the kitchen. The FSD said the microwave was used to reheat resident food when a unit calls down after meal service for additional items to ensure the food is hot. The FSD said the microwave is cleaned daily. The FSD said the microwave should not have any burn-like residue/stains and needed to be replaced. The FSD said all opened drink items in the reach-in refrigerator should be labeled with an open date and use by date. The FSD said the pitcher contained a milk substance and should have been labeled. 2. The surveyor, with the FSD present, made the following observations of the ice machine in the main kitchen:- 12/5/25 at 7:45 A.M.: Orange stains/spots to the white plastic portion of the upper inside of the ice machine and black/orange stains to the back portion of the machine; Vendor sticker indicated 8/11/25.- 12/9/25 at 11:00 A.M.: Orange stains/spots to the white plastic portion of the upper inside of the ice machine and black/orange stains to the back portion of the machine; Vendor sticked indicated 8/11/25. During an interview on 12/10/25 at 9:00 A.M., the FSD said the ice machines are cleaned quarterly by an outside vendor and cleaned monthly by the facility. The FSD said there should be no residue in the ice machine, and they needed to be cleaned. 3. On 12/9/25 at 11:10 A.M., the surveyor made the following observations during the lunch line service:- At 11:12 A.M., Dietary Staff #2 began taking temperatures of all the food items on the service line.- At 11:14 A.M., Dietary Staff #2 walked from the food service line to the trash can, used an alcohol wipe to clean the thermometer, touch the top of the trash can with both hands and returned to the food service line to take the temperature of the next food item.- At 11:15 A.M., Dietary Staff #2 walked from the food service line to the trash can, used an alcohol wipe to clean the thermometer, touch the top of the trash can with both hands and return to the food service line to take the temperature of the next food item.- At 11:17 A.M., Dietary Staff #2 walked from the food service line to the trash can, used an alcohol wipe to clean the thermometer, touch the top of the trash can with both hands and return to the food service line to take the temperature of the next food item.- At 11:19 A.M., Dietary Staff #2 walked from the food service line to the trash can, used an alcohol wipe to clean the thermometer, touch the top of the trash can with both hands and return to the food service line to take the temperature of the next food item.- At 11:21 A.M., Dietary Staff #2 walked from the food service line to the trash can, used an alcohol wipe to clean the thermometer, touch the top of the trash can with both hands and return to the food service line to take the temperature of the next food item. During an interview on 12/10/25 at 9:05 A.M., the FSD and the surveyor reviewed the observations made during the food line service. The FSD said hand hygiene should have been completed prior to returning to the food service line to take food temperatures.

Based on record review and interviews, the facility failed to ensure that all drug records were in order and an accurate account of all controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) was maintained for one Resident (#15), from a total sample of 24 residents.Findings include:Resident #15 was admitted to the facility in July 2020 and had diagnoses including dementia with behavioral disturbance, low back pain, and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 11/3/25, indicated Resident #15 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15 and received Hospice services.Review of the medical record indicated Physician's Orders including but not limited to:-Lorazepam concentrate (schedule-IV controlled substance (low potential for abuse and a low risk of dependence) 2 milligrams per milliliter (mg/ML), give 0.5 mg (0.25 mL) sublingually two times a day (11/7/25)-Lorazepam oral concentrate 2 mg/ml, give 0.5 mg (0.25 mL) by mouth every 1 hour as needed (PRN) for anxiety/agitation/restlessness until 12/7/25; for 30 days started on 11/8/25Review of the November 2025 and December 2025 Medication Administration Record (MAR) and the controlled substance logbook indicated a 30 mL bottle was received from the pharmacy on 11/8/25. From 11/8/25 at 7:00 P.M. to 11/16/25 at 7:00 P.M., 15 doses of Lorazepam were documented as administered to Resident #15 for a total of 3.75 mL with 26.25 mL remaining in the bottle.The controlled substance count conducted by Nurse #7 and Nurse #1 on 11/16/25 at 3:00 P.M. indicated the status of the count was not exact.Review of a Nurse's Note written by Nurse #7, dated 11/16/25, indicated the narcotic count was off and the remaining amount of Lorazepam should be 26.25 mL. However, only 22 mL remained in the bottle (4.25 mL or 16% discrepancy). Per outgoing nurse, discrepancy to be rectified by the Director of Nursing (DON) prior to further administration.During a telephonic interview on 12/10/25 at 12:38 P.M., Nurse #7 said she identified a discrepancy with the narcotic count on 11/16/25 at 3:00 P.M. while doing count with Nurse #1. She said when the count was identified as off, Nurse #1 called the supervisor and was told the DON would rectify the discrepancy. Nurse #7 said she noted the Ativan bottle to be sealed tightly with no leakage noted in the cart.The controlled substance count conducted by Nurse #9 and Nurse #7 on 11/16/25 at 11:00 P.M., failed to indicate if the count was exact or not (blank).During a telephonic interview on 12/10/25 at 11:07 A.M., Nurse #9 said she recalls doing the narcotic count with Nurse #7 on 11/16/25 at 11:00 P.M. and there was a discrepancy with the Lorazepam. She said she should have documented no in the box indicating the count was not exact, but she did not. Nurse #9 said she observed the Ativan bottle to be sealed tightly with no leakage noted. She said she did not report the discrepancy because she was told it had already been reported earlier in the day.The controlled substance count conducted by Nurse #1 and Nurse #9 on 11/17/25 at 7:00 A.M. indicated the count was not exact.An entry in the controlled substance logbook written by Nurse #1 for Lorazepam, dated 11/17/25 at 9:30 A.M., indicated the words miss calculation (sic) and the amount of Lorazepam remaining in the bottle was 22.5 mL (previous amount remaining was 26.25 mL). This reflects a discrepancy of 3.75 mL, which equals 15 (0.25 mL doses). The entry was co-signed by the DON.Although the entry dated 11/17/25 at 9:30 A.M. adjusted the amount of Lorazepam on hand from 26.25 mL to 22.5 mL, the controlled substance count conducted by Unit Manager #1 and Nurse #1 on 11/17/25 at 3:00 P.M., was signed as not exact by Unit Manager #1 and was not signed by Nurse #1.During an interview on 12/10/25 at 9:17 A.M., Nurse #1 said she did count with Nurse #9 on 11/17/25 at 7:00 A.M and signed that the count was not exact. She said she did not report the continued discrepancy because it was reported the previous day. Nurse #1 said she was the nurse that did count with Unit Manager #1 on 11/17/25 at 3:00 P.M but she forgot to sign off. She said she cannot recall if the count was exact or not that day but was asked by the DON to sign it off and date her signature 12/8/25.During an interview on 12/8/25 at 2:45 P.M., the surveyor reviewed the controlled substance logbook with Unit Manager #1. He confirmed that he did count with Nurse #1 on 11/17/25 at 3:00 P.M. and signed the log as not accurate. He said he did not notify a supervisor or DON of the inaccuracy.During interviews with the DON and Assistant Director of Nursing (ADON) on 12/8/25 at 2:40 P.M. and 12/9/25 at 11:20 A.M. and 1:35 P.M., the DON said he remembers hearing something about a discrepancy in the controlled substance logbook shift count but could not remember the specifics. He said the ADON was probably involved with that. The ADON said she received a call from the nursing supervisor on 11/16/25 (Sunday) and was told the count was off. She said she told the nursing supervisor to check the math and make sure it was correct. She said she did not hear anything else about it and assumed everything was okay. They said they were not made aware of any leakage with Resident #15's Ativan bottle and no one had reported any spillage. Both the DON and ADON said they were not aware of three subsequent discrepancies noted in the controlled substance logbook from 11/16/25 at 11:00 P.M. to 11/17/25 at 3:00 P.M. and did not investigate the discrepancy reported on 11/16/25 at 3:00 P.M. The DON said on 11/17/25 at 9:00 A.M., although he doesn't recall, he must have looked at the Lorazepam administration in the logbook and the numbers looked right, so he signed off on it. The surveyor reviewed Resident #15's November MAR and the controlled substance logbook with the DON. He said there are several inaccuracies in the logbook such as a blank area (Status of count: Yes/No) on 11/16/25 and a missing nurse signature on 11/17/25 in which the oncoming nurse signed the count as not exact. He said there should be no blanks areas in the logbook, and he should not have asked Nurse #1 to sign off on the 11/17/25 count when she could not recall if it was accurate or not. The DON and ADON said they have done audits of the controlled substance logbooks in the past but cannot recall the last time an audit was done and were unable to provide the survey team with any evidence that periodic audits/reconciliations had been done by the DON or ADON.Review of the medical record indicated the consultant pharmacist performed a medication regimen review (MRR) on 11/29/25 with no irregularities noted.During an interview on 12/9/25 at 11:41 A.M., the consultant Pharmacist said she has remote access to the electronic medical record and conducts her monthly MRRs off-site. She said she reviews all parts of the medical record including physician's orders, medication administration records and progress notes. She said she did not see the 11/16/25 Nurse's note in which the nurse identified that the narcotic count was off during her 11/29/25 MRR for Resident #15. She said there is an allowable discrepancy, especially with liquid medications to account for spillage, which is about 5%. I reviewed the Nurse's note and narcotic logbook documentation which indicated a 30 mL bottle was received on 11/8/25 and a 4.25 mL discrepancy identified on 11/16/25. She said that 4.25 mL is not an acceptable amount of discrepancy and if she saw the note, she would have brought it to the DON's attention for investigation. The Pharmacist said the pharmacy does periodic on-site visits for inspections that include the medication rooms and medication carts and serve as a second set of eyes for the facility. She said they make recommendations to the facility, and it is up to them to address it. The consultant Pharmacist said an on-site visit was conducted in November and a copy of the report was provided to the DON.Review of the on-site pharmacy visit report, dated 11/10/25, failed to indicate any concerns with the integrity of Resident #15's bottle of liquid Ativan stored in either the medication cart or medication room refrigerator on the B-Wing where Resident #15 resides.

Based on record review and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#2) who required hemodialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to), out of a total sample of 24 residents. Specifically, the facility failed:a. to ensure nursing staff did not obtain blood pressures from the Resident's arms, where his/her AV fistulas (arteriovenous fistula, where an artery and vein connect directly, allowing blood to flow) used for hemodialysis access were located; andb. to obtain and implement physician's orders for the care and maintenance of the Resident's hemodialysis catheter (a surgically placed catheter connected to a central vein that exits the skin and attaches to the tubing on the dialysis machine) upon his/her return from the hospital; andc. to administer the Resident's phosphorus binder (a medication used to reduce the absorption of dietary phosphate) with meals per the Resident's physician's order.Findings include:Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised 7/2023, indicated, but was not limited to, the following:-The facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice.-The resident's comprehensive care plan will reflect the resident's needs related to ESRD (end-stage renal disease)/dialysis care.Resident #2 was admitted to the facility in March 2025 with diagnoses including end stage renal disease.Review of Resident #2's Minimum Data Set (MDS) assessment, dated 9/5/25, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS assessment indicated the Resident received dialysis treatment.Review of Resident #2's Physician's Orders indicated, but was not limited to, the following:-AV fistula R (right) brachial forearm check thrill and bruit each shift (order date: 3/10/25)-Central Venous Cath: IJ (internal jugular) right chest every shift for site use for dialysis, monitor site q (every) shift (order date: 3/12/25)-Dialysis center: [Dialysis Center name, address, phone] Days: Tuesdays-Thursdays and Saturdays every day shift every Tue, Thu, Sat pick up 5:45 A.M. by stretcher (order date: 3/7/25)-Monitor AV Fistula to Left arm for intactness every shift and PRN (as needed) (order date: 6/6/25)-Monitor dialysis access site dressing right chest every shift (order date: 3/7/25)-No Blood Pressure/Blood Draws to be taken in the right arm every shift (order date: 3/10/25)-Sevelamer Carbonate (a phosphorus-binding medication) Oral Tablet 800 mg (milligrams) Give 1 tablet by mouth with meals for managing high blood phosphate levels (hyperphosphatemia) Swallow whole. Do Not Chew or Crush. Take with meals (order date: 9/23/25)Review of Resident #2's Care Plan indicated, but was not limited to, the following:-Focus: NUTRITION: [Resident #2] is at high risk for malnutrition r/t (related to) hemorrhage, atrophy, T2DM (type 2 diabetes mellitus), ESRD w/ dialysis (end-stage renal disease with dialysis), palliative care, mod pro cal mal (moderate protein-calorie malnutrition), UTI (urinary tract infection), dementia, bowel regimen. Significant weight changes.Interventions: 07. Administer medications as ordered.-Focus: [Resident #2] has potential for complications r/t hemodialysis for diagnosis of End Stage Renal FailureInterventions:*Administer/monitor effectiveness of medications as ordered*Central Venous Cath: IJ Right Chest dialysis accessing, monitor site q shift*Monitor shunt site by palpating for thrill and auscultating for bruit daily. Notify physician of absence of thrill or bruit.*Protect access site from injury. Site: Right AV fistula no used for accessing dialysis [sic]*Avoid constriction on affected right arm, such as constrictive clothingNo BP on right arm with AV fistula dialysis catheter-Focus: Central Catheter: Potential for infection and/or trauma related to catheter direct access to blood.Catheter is not used by nursing staff - used for hemodialysis onlyInterventions:*Catheter is not to be accessed by nursing staff. Notify MD with any abnormal findings.*Report any abnormal findings to physician-Focus: [Resident #2] needs dialysis r/t diagnosis of End Stage Renal DiseaseInterventions:*Administer medications as ordered*Check AV fistula site for signs/symptoms of infection, pain, or bleeding daily and PRN*Do not draw blood or take B/P in right arm with AV fistula*Monitor/document/report PRN any signs/symptoms of infection to access site: redness, swelling, warmth or drainagea. Review of Resident #2's medical record indicated his/her right arm AV fistula was created in December 2024 and his/her left arm AV fistula was created in June 2025. Review of Resident #2's Weights and Vitals Summary indicated between 3/7/25 and 11/29/25, the Resident's blood pressure was recorded in his/her electronic medical record 43 times. Of those 43 times, 26 blood pressures were recorded as taken in the Resident's left arm, 15 blood pressures were recorded as taken in the Resident's right arm, and 2 blood pressures were recorded with no location indicated. No blood pressures were recorded as taken in the Resident's left or right leg. During an interview on 12/8/25 at 12:05 P.M., Nurse #2 said Resident #2 had an AV fistula for dialysis in his/her right arm, but it stopped working and a tunneled hemodialysis catheter and left AV fistula were put in. During an interview on 12/9/25 at 7:40 A.M., Nurse #3 said she usually takes Resident #2's blood pressure in his/her legs because he/she has dialysis fistulas in both arms.During a subsequent interview on 12/9/25 at 11:24 A.M., Nurse #2 said he usually takes Resident #2's blood pressure in his/her right wrist.During an interview on 12/9/25 at 4:02 P.M., the Assistant Director of Nursing (ADON) said Resident #2's blood pressure should be taken in his/her leg.During an interview on 12/10/25 at 10:51 A.M., the Director of Nursing (DON) said Resident #2's blood pressure should be taken in his/her leg because of the AV fistulas in his/her right and left arms.b. Review of Resident #2's Progress Notes indicated on 12/7/25 at 11:58 P.M., the Resident's dialysis catheter dressing was missing, and Nurse #4 cleaned the area and placed a new dressing. Nurse #4 also documented the Resident had scratched loose a few sutures from the line. Further review of Resident #2's Progress Notes failed to indicate the physician was notified that the Resident's dialysis catheter dressing had been removed and the Resident had scratched loose sutures from the line.Review of Resident #2's Physician's Orders failed to indicate a physician's order was obtained to cleanse and apply a new dressing to the Resident's dialysis catheter.During an interview on 12/9/25 at 4:25 P.M., Nurse #4 said when she assessed Resident #2's dialysis catheter on 12/7/25, there was no dressing and two sutures were intact. Nurse #4 said she applied a new dressing to the dialysis catheter but did not notify the physician that the dressing was off and sutures were scratched loose because the cuff (part of the catheter made of fabric or synthetic material that anchors the device and creates in infection-preventing seal by encouraging tissue growth) was not out of the skin. During an interview on 12/10/25 at 10:42 A.M., Physician #1 said he was not aware that Resident #2's dialysis catheter dressing was not in place on 12/7/25 or that Nurse #4 was concerned that the Resident had loosened his/her sutures. Physician #1 said it was his expectation that the nursing staff would call and inform the provider if the Resident's dialysis catheter dressing needed to be replaced or if there was a concern that the sutures had been loosened or removed.During an interview on 12/10/25 at 10:51 A.M., the DON said Nurse #4 should have called the physician when she became aware that Resident #2's hemodialysis catheter dressing was not in place to inform him and obtain an order to dress the hemodialysis catheter. The DON said he thought Nurse #4 may not have documented the condition of the sutures accurately and maybe it was her first time seeing the hemodialysis catheter without a dressing. The DON said he was not sure if any sutures were out/loosened by the Resident. c. Review of Resident #2's medical record indicated he/she was transported to/from dialysis by ambulance and his/her pickup time from the facility was scheduled for 5:45 A.M. Review of Resident #2's Physician's Orders indicated he/she should be taking a phosphorus-binding medication with meals. Review of Resident #2's Dialysis Communication Forms 9/30/25 through 12/9/25 indicated Resident #2 ate breakfast at the facility prior to leaving for dialysis and no phosphorus-binding medications were administered within the four hours before he/she left.Review of Resident #2's Medication Administration Record (MAR) October 2025 through December 2025 indicated the Resident was scheduled to receive his/her phosphorus-binding medication at 7:15 A.M. every day. During an interview on 12/9/25 at 7:15 A.M., Nurse #3 said Resident #2 leaves the facility early for dialysis and eats breakfast before leaving at 5:45 A.M. Nurse #3 said she does not administer the Resident's phosphorus-binding medication when the Resident eats breakfast because the medication is scheduled to be administered at 7:15 A.M.During an interview on 12/9/25 at 7:16 A.M., Nurse #2 said Resident #2 should be taking his/her phosphorus-binding medication with all meals.During an interview on 12/10/25 at 10:42 A.M., Physician #1 said Resident #2's phosphorus-binding medication should be administered with meals.During an interview on 12/10/25 at 10:51 A.M., the DON said Resident #2's phosphorus-binding medication should be scheduled for administration when the Resident receives his/her early breakfast on Tuesday, Thursday, and Saturday before dialysis.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for four Residents (#23, #6, #2, #12), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #23, to implement physician's orders for air mattress settings;2. For Resident #6, to transcribe and implement Urology orders (a) for change in Foley catheter size, and (b) for frequency of Foley catheter changes;3. For Resident #2, to obtain a physician's order for treatment to the Resident's right thigh surgical wound; and4. For Resident #12, to follow physician's orders to notify the Resident's cardiologist for systolic blood pressure below 90 mmHg (millimeters of mercury) and/or heart rate below 60 bpm (beats per minute). Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Medication and Treatment Orders, revised 9/2024, indicated, but was not limited to, the following:-Orders for medications and treatments will be consistent with regulatory standards.-Medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state.-Verbal orders must be recorded in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. 1. Resident #23 was admitted to the facility in September 2022 with diagnoses including dementia, history of falling and osteoporosis. Review of Resident #23's Minimum Data Set (MDS) assessment, dated 10/24/25, indicated he/she had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Furthermore, the MDS assessment indicated he/she was dependent for all mobility and had a pressure-reducing device on their bed. Review of Resident #23's Physician's Orders indicated but was not limited to: - 2/2/24: maintain resident on a pressure reducing mattress while in bed, set at number 4 (check function QSHIFT (every shift)); every shift for skin care. On the following dates and times, the surveyor made the following observations of Resident #23's air mattress settings: - 12/5/25 at 10:18 A.M.: air mattress set to level 6. - 12/9/25 at 7:57 A.M.: air mattress set to level 6. - 12/9/25 at 12:51 P.M.: air mattress set to level 6. Review of Resident #23's December Treatment Administration Record (TAR) failed to indicate his/her air mattress settings were checked every shift. During an interview on 12/9/25 at 2:43 P.M., Nurse #2 said each shift air mattress settings and function are checked and recorded on the TAR for those residents utilizing the devices. Nurse #2 reviewed Resident #23's medical record and said he/she had an air mattress, and it should be set to level four. Nurse #2 reviewed Resident #23's TAR and said there were no orders on the TAR to check the setting or air mattress function and it was not being checked off by nursing staff. Nurse #2 and the surveyor checked Resident #23's air mattress setting. Nurse #2 said the air mattress was set to level 6 and lowered it to level 4 before exiting the room. During an interview on 12/9/25 at 3:24 P.M., the Assistant Director of Nursing (ADON) said all residents with orders for air mattresses should have their setting and function checked each shift by the nurse. The ADON said the orders should populate to the TAR. The ADON and the surveyor reviewed the observations made throughout the survey. The ADON said the Resident's air mattress should have been set correctly and marked on the TAR by the nursing staff. 2. Resident #6 was admitted to the facility in August 2021 with diagnoses including cerebral infarction and obstructive and reflux uropathy. Review of Resident #6's MDS assessment, dated 11/14/25, indicated he/she had a moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. Furthermore, the MDS assessment indicated he/she was dependent for functional mobility and had an indwelling catheter. Review of Resident #6's Physician's Orders indicated but were not limited to: - 7/25/24: Foley catheter 18FR (French)/10mL (milliliter) continuous to drainage bag every shift. - 7/25/24: Foley care every shift. - 4/13/25: Change Foley catheter bag every other Sunday 11-7 shift. a. Review of Resident #6's Urology consult report, dated 11/21/25, indicated the following: - Catheter change every four weeks with 20 French. - Changed today, due again on 12/21/25. Review of Resident #6's comprehensive care plan for an indwelling Foley catheter (initiated 8/24/21), indicated but was not limited to the following: - Catheter: change catheter (as needed/clogged) (18FR/10mL) (Foley). - Catheter: Resident has 18FR/10mL; position catheter bag and tubing below the level of the bladder and away from entrance room door. Review of Resident #6's medical record failed to indicate documentation showing a change in Resident #6's Foley catheter size from an 18FR to 20FR. During an interview on 12/9/25 at 2:49 P.M., Nurse #2 said the Resident has had a Foley catheter for some time. Nurse #2 said he/she goes to Urology, but they did not go regularly. Nurse #2 and the surveyor reviewed Urology recommendations from 11/21/25 and Resident #6's medical record. Nurse #2 said the medical record should have been updated to reflect the change in Resident #6's Foley catheter size and it was not. During an interview on 12/9/25 at 3:26 P.M., the ADON said the Resident's orders should have been updated to reflect the change in Foley catheter size after the Urology appointment. b. Review of Resident #6's Urology consult report, dated 8/18/25, indicated the following: - Continue to change catheter every 4 weeks. Review of Resident #6's Urology consult report, dated 11/21/25, indicated the following: - Catheter change every four weeks with 20 French. - Changed today, due again on 12/21/25. Review of Resident #6's TAR from August 2025 to November 2025 failed to indicate his/her Foley catheter was changed every four weeks. During an interview on 12/9/25 at 2:49 P.M., Nurse #2 and the surveyor reviewed the Urology consult reports and Resident #6's medical record. Nurse #2 said Resident #6's Foley catheter should be changed every four weeks per the Urology report but it was not reflected in the medical record. During an interview on 12/9/25 at 3:26 P.M., the ADON said Resident #6 should have an order to change the Foley catheter every four weeks and did not. 3. Resident #2 was admitted to the facility in March 2025 with diagnoses including end-stage renal disease dependent on hemodialysis. Review of Resident #2's MDS assessment, dated 9/5/25, indicated the Resident was cognitively intact, as evidenced by a BIMS score of 14 out of 15. Review of Resident #2's medical record indicated the Resident had sustained a fall and was transferred to the hospital on [DATE]. Further review indicated the Resident was found to have a right hip fracture and underwent surgical repair of the fracture on 11/24/25. The Resident returned to the facility on [DATE]. Review of Resident #2's Physician's Orders indicated, but was not limited to, the following:-Dressing on right hip site should remain in place till follow appointment [sic] in 2 weeks with [Orthopedic Surgeon] in 2 weeks every shift for monitoring for 14 days (order date 11/26/25) Review of Resident #2's Progress Notes indicated, but was not limited to, the following:-12/4/25 at 6:06 A.M.: Resident has left the facility with [ambulance company] transport via stretcher. He/she ate 100% of early breakfast. His/her vital signs are stable. He/she continues with healing right hip fracture pulses were palpated and CSM (circulation, sensation, motion) positive. Dress [sic] on the right thigh had fallen off. Staples were intact and skin well approximated. I put Abd pad on him/her for now. Further review of the Resident's Physician's Orders and Progress Notes failed to indicate the physician was notified the dressing had fallen off or new treatment orders were obtained for care of the surgical wound. During an interview on 12/9/25 at 7:38 A.M., Nurse #3 said on 12/4/25, one of the Resident's surgical dressings had come off. Nurse #3 said at that time, she put another dressing over the surgical wound, but now it is open to air. Nurse #3 said she did not notify the physician and wasn't sure if the physician or orthopedic surgeon's office was notified that the Resident's right hip dressing had come off before his/her follow-up appointment. On 12/9/25 at 11:24 A.M., the surveyor observed Nurse #2 applying an abdominal pad (an absorbent dressing) secured with tape on Resident #2's right lateral thigh over two surgical incisions closed with staples. Nurse #2 said Resident #2 was going out to an appointment with the orthopedic surgeon later that day. During an interview on 12/10/25 at 10:42 A.M., Physician #1 said it is his expectation that the facility's nursing staff contact the provider for new dressing or treatment orders. During an interview on 12/10/25 at 10:51 A.M., the Director of Nursing (DON) said the physician should have been notified when Resident #2's right hip dressing came off, and new treatment orders should have been obtained before a new dressing was applied. 4. Resident #12 was admitted to the facility in January 2019 with diagnoses including heart failure. Review of Resident #12's MDS assessment, dated 9/12/25, indicated the Resident was cognitively intact, as evidenced by a BIMS score of 15 out of 15. Review of Resident #12's Physician's Orders indicated, but was not limited to, the following:-Metoprolol tartrate 25 milligrams (mg) Give one tablet by mouth one time a day for coronary artery disease notify MD if SBP (systolic blood pressure) below 90 and or HR (heart rate) below 60 (order date 6/18/25) Review of Resident #12's Medication Administration Record (MAR) indicated, but was not limited to the following:-On 7/3/25, the Resident's SBP was 74 mmHg. Metoprolol tartrate 25mg was administered.-On 11/13/25, the Resident's SBP was 79 mmHg. Metoprolol tartrate was not administered due to vital signs out of parameters.-On 11/14/25, the Resident's SBP was 88 mmHg. Metoprolol tartrate 25mg was administered.-On 11/16/25, the Resident's HR was 55 bpm (beats per minute). Metoprolol tartrate 25mg was administered. -On 11/21/25, the Resident's SBP was 88 mmHg. Metoprolol tartrate was not administered due to vital signs out of parameters. -On 12/1/25, the Resident's SBP was 81 mmHg. Metoprolol tartrate was not administered due to vital signs out of parameters. Review of Resident #12's Progress Notes failed to indicate the Resident's cardiologist was notified when his/her SBP was below 90 mmHg or HR was below 60 bpm. During an interview on 12/9/25 at 2:54 P.M., Nurse #2 said if Resident #12's vital signs were outside of the parameters given in the order (SBP below 90mmHg and HR below 60 bpm), the medication should be held and the physician notified. Nurse #2 said if the physician was notified, it should be documented in the Resident's Progress Notes. During an interview on 12/9/25 at 4:03 P.M., the ADON said Resident #12's cardiologist's office had called and recommended the Resident be started on Metoprolol and wanted the facility to monitor the Resident's blood pressure and to call their office if his/her blood pressure was low. The ADON said if the physician's order said to call the cardiologist's office for vital signs out of parameters, the cardiologist's office should have been called. During an interview on 12/10/25 at 10:51 A.M., the DON said the nurses should have been following the physician's order and calling the cardiologist when the Resident's vital signs were noted to be out of parameters.

Based on observation, interview, and record review, the facility failed to develop, implement, and individualize a comprehensive care plan for three Residents (#5, #73, #29), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #5, to ensure a comprehensive care plan was developed and implemented related to his/her use of antipsychotic medications;2. For Resident #73, to ensure a comprehensive care plan was developed and implemented related to his/her use of antipsychotic medications; and3. For Resident #29, to ensure a comprehensive care plan was developed and implemented related to his/her smoking status and preferences. Findings include:Review of the facility's policy titled Care Plans, comprehensive Person-centered, dated last revised 1/2024, indicated but was not limited to the following: - A comprehensive, person-centered care plan will be developed for each resident. - The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. - The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive, care plan for each resident. - The care plan interventions are derived from information gathered as part of the comprehensive assessment. - The IDT reviews and updates the care plan when there has been a significant change in the resident's condition, when there is a change, and at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. 1. Resident #5 was admitted to the facility in June 2025 with diagnoses including post-traumatic stress disorder, anxiety, and dementia. Review of Resident #5's MDS assessment, dated 9/11/25, indicated he/she utilized antipsychotic medication on a routine basis. Review of Resident #5's Physician's Orders indicated but were not limited to the following: - 6/23/25: Quetiapine Fumarate (Seroquel) tablet 25MG (milligrams); give 12.5MG by mouth two times a day for mood. Review of Resident #5's comprehensive care plans failed to indicate an antipsychotic care plan was developed or implemented. During an interview on 12/10/25 at 10:17 A.M., Unit Manager (UM) #1 said all residents who utilize antipsychotic medication should have a care plan. UM #1 and the surveyor reviewed Resident #5's comprehensive care plans. UM #1 said there was not a care plan for antipsychotic medication use and there should be. During an interview on 12/10/25 at 11:12 A.M., the Director of Nursing (DON) said all residents who utilize antipsychotic medication should have a care plan reflecting their use. 2. Resident #73 was admitted to the facility in November 2021 with diagnoses including bipolar disorder, dementia with behavioral disturbances and anxiety. Review of the MDS assessment indicated Resident #73 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and had utilized antipsychotic medication on a routine basis. Review of Resident #73's Physician's Orders indicated but were not limited to the following: -Risperdal Oral tablet 0.5 MG; give 0.5 MG by mouth at bedtime for paranoia/delusions (dated 12/20/24) Review of Resident #73's Medication Administration Record (MAR) for November 2025 and December 2025 indicated he/she had received Risperdal as ordered. Further review of the physician's orders and medical record did not indicate staff were monitoring for side effects from an antipsychotic medication (Risperdal). Review of Resident #73's comprehensive care plans failed to indicate an antipsychotic care plan was developed or implemented. During an interview on 12/9/25 at 12:15 P.M., the Assistant Director of Nursing (ADON) said all residents who utilize antipsychotic medication should have a care plan. The ADON and the surveyor reviewed Resident #73's comprehensive care plans. The ADON said she did not see a care plan for antipsychotic medication use and there should be one. During an interview on 12/10/25 at 11:12 A.M., the DON said all residents who utilize antipsychotic medication should have a care plan reflecting their use. 3. Resident #29 was admitted to the facility in December 2023 with diagnoses including dementia and chronic obstructive pulmonary disease. Review of Resident #29's MDS assessment, dated 11/14/25, indicated the Resident was cognitively impaired, as evidenced by a BIMS score of 8 out of 15. The MDS assessment indicated the Resident did not use tobacco. Review of the facility's list of residents who smoke, provided to the survey team on 12/5/25, indicated Resident #29 smoked with his/her family only. Review of Resident #29's Smoking Evaluation, dated 5/24/25, indicated the Resident smoked, was safe to smoke with supervision without protective smoking equipment, and was able to light his/her own cigarette with staff assistance. Review of Resident #29's Care Plans failed to indicate a care plan was developed for the Resident's tobacco use. During an interview on 12/9/25 at 10:53 A.M., Nurse #5 said Resident #29 does not routinely smoke during the facility's smoking times but will smoke on occasion during visits with his/her daughter. Nurse #5 said the Resident's daughter assists him/her with smoking outside and that his/her cigarettes and lighter are kept at the nurses' station for when he/she does request to go out to smoke. During an interview on 12/9/25 at 4:21 P.M., Unit Manager #2 said Resident #29 only goes out to smoke when his/her daughter comes to visit. Unit Manager #2 said Resident #29's daughter will assist the Resident outside and they will smoke together. During an interview on 12/10/25 at 10:51 A.M., the DON said Resident #29 smokes with his/her daughter and should have a care plan in his/her medical record to address his/her tobacco use.

Based on observation and interview, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor and appearance as well as being palatable, attractive and at safe, appetizing temperatures for two of two test trays. Findings include:During initial screening on 12/5/25, surveyors obtained the following food concerns on the B-Wing and C-Wing units:- Food is not good and often not palatable to eat.- Food is repetitive and often cold.- The French toast is cold and soggy.- Vegetables are often cold, mushy and overcooked.- Food is cold at all mealtimes.- The temperature of the food is not good.- Toast is always soggy. On 12/9/25 at 11:30 A.M., the surveyor requested a test tray to the C-Wing unit and made the following observations:- At 11:47 A.M., the food truck containing the test tray leaves the kitchen for the C-Wing unit.- At 11:50 A.M., the food truck arrives on the C-Wing unit and staff begin passing trays.- At 11:58 A.M., the last tray is delivered to a resident from the food truck. On 12/9/25 at 12:00 P.M., the surveyor and the Food Service Director (FSD) completed the test tray together and the food temperatures were as follows:- Soup: 106 F (Fahrenheit); cold to taste- Riced Cauliflower: 118 F; cold to taste, no seasoning/flavor- Egg Noodles: 112 F: cold to taste, no seasoning/flavor- Beef Stroganoff: 104 F; flavorful but meat is cold to taste During an interview on 12/9/25 at 12:04 P.M., the FSD said the hot food items were too cold and she would expect them to be hotter and closer to 130 F. On 12/10/25 at 7:32 A.M., the surveyor requested a second test tray to the B-Wing unit and made the following observations:- At 7:58 A.M., the food truck containing the test tray leaves the kitchen for th e B-Wing unit.- At 7:59 A.M., the food truck arrives on the B-Wing unit and staff begin passing trays.- At 8:09 A.M., the last tray is delivered to a resident from the food truck. On 12/10/25 at 8:10 A.M., the surveyor and Nurse #1 completed the test tray together and the food temperatures were as follows:- Hot Cereal: 120 F; lukewarm temperature, bland flavoring- Eggs: 117 F; cold to taste; bland flavoring- Toast: 100 F; lukewarm temperature, soggy During an interview on 12/10/25 at 9:00 A.M., the FSD and surveyor reviewed the second test tray results from the B-Wing unit. The FSD said she would expect temperatures to be hotter. The FSD said food temperatures should be closer to 130 F when served to residents.

Based on record review and interview, the facility failed to ensure two Residents (#8 and #9), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended COVID-19 vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed:1. For Resident #8, to ensure COVID-19 vaccine was administered after the Resident had consented to receive the vaccine; and 2. For Resident #9, to ensure the Resident's medical record included documentation that indicated the Resident's Representative was provided education regarding the benefits and potential side effects of COVID-19 vaccination and either consented to receive or refused vaccine administration. Findings include:Findings include:1. Resident #8 was admitted to the facility in September 2025 with diagnoses including heart failure.Review of Resident #8's Immunization Consent indicated that the Resident had declined COVID-19 vaccination on 9/24/25. On 10/16/25, Resident #8 signed a new Immunization Consent and consented to administration of COVID-19 vaccine/booster. Review of Resident #8's medical record failed to indicate the Resident had received the 2025-2026 COVID-19 vaccine after he/she had consented to its administration.During an interview on 12/10/25 at 9:34 A.M., Unit Manager #2 said Resident #8 had initially refused all vaccines, but a new consent was completed when the Resident returned from a hospitalization and the Resident had consented to administration of all vaccines. 2. Resident #9 was admitted to the facility in November 2025 with diagnoses including dementia and diabetes.Review of Resident #9's medical record indicated a guardian (someone appointed by the court responsible for making decisions for another person) had been appointed on 6/6/21.Review of Resident #9's medical record failed to include documentation that indicated the Resident's guardian was provided education regarding the benefits and potential side effects of COVID-19 vaccination and either consented to receive or refused vaccination.During an interview on 12/9/25 at 3:30 P.M., the Assistant Director of Nursing (ADON) said the facility offers COVID-19 vaccination to all eligible residents and all residents who consent to vaccination should receive the vaccine as soon as possible. The ADON said vaccine consent and administration is recorded in the electronic medical record. During an interview on 12/10/25 at 10:24 A.M., Unit Manager #2 said the nurse assigned to a resident would complete the Immunization Consent form with the resident when they are first admitted to the facility. Unit Manager #2 said she would check the Immunization Consent form the next day and that the Medical Records Coordinator would also check the Immunization Consent form to ensure it is completed. Unit Manager #2 said if a resident consented to vaccine administration, any nurse could input the order for the vaccine in the electronic medical record for administration.During an interview on 12/10/25 at 10:51 A.M., the Director of Nursing (DON) said he is responsible for tracking and reporting resident vaccine administration. The DON said if a resident consents to COVID-19 vaccination, the vaccine should be administered as soon as possible.

Based on record review and interview, the facility failed to ensure two Residents (#8 and #9), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended influenza and pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccines, and were offered and administered (if applicable) the vaccines in a timely manner. Specifically, the facility failed:1. For Resident #8, to ensure influenza and pneumococcal vaccines were administered after the Resident had consented to receive the vaccines; and 2. For Resident #9, to ensure the Resident's medical record included documentation that indicated the Resident's Representative was provided education regarding the benefits and potential side effects of influenza vaccination and either consented to receive or refused vaccine administration. Findings include:Review of the facility's policy titled Influenza Vaccine, revised 11/2020, indicated, but was not limited to, the following:-All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.-Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized.-Residents admitted to the facility between October 1st and March 31st shall be offered the vaccine.-Prior to vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine.-A resident's refusal of vaccine shall be documented. -Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.1. Resident #8 was admitted to the facility in September 2025 with diagnoses including heart failure.Review of Resident #8's Immunization Consent indicated that the Resident had consented to annual influenza vaccine administration but declined pneumococcal vaccination on 9/24/25. On 10/16/25, Resident #8 signed a new Immunization Consent and consented to annual administration of influenza vaccine and consented to the recommended schedule of administration of pneumococcal vaccination. Review of Resident #8's medical record failed to indicate the Resident had received the 2025-2026 influenza vaccine or pneumococcal conjugate vaccine after he/she had consented to their administration.During an interview on 12/10/25 at 9:34 A.M., Unit Manager #2 said Resident #8 had initially refused all vaccines, but a new consent was completed when the Resident returned from a hospitalization and the Resident had consented to administration of all vaccines. 2. Resident #9 was admitted to the facility in November 2025 with diagnoses including dementia and diabetes.Review of Resident #9's medical record indicated a guardian (someone appointed by the court responsible for making decisions for another person) had been appointed on 6/6/21.Review of Resident #9's medical record failed to include documentation that indicated the Resident's guardian was provided education regarding the benefits and potential side effects of influenza vaccination and either consented to receive or refused vaccination.During an interview on 12/9/25 at 3:30 P.M., the Assistant Director of Nursing (ADON) said the facility offers influenza vaccination to all eligible residents and all residents who consent to vaccination should receive the vaccine as soon as possible. The ADON said vaccine consent and administration is recorded in the electronic medical record. During an interview on 12/10/25 at 10:24 A.M., Unit Manager #2 said the nurse assigned to a resident would complete the Immunization Consent form with the resident when they are first admitted to the facility. Unit Manager #2 said she would check the Immunization Consent form the next day and that the Medical Records Coordinator would also check the Immunization Consent form to ensure it is completed. Unit Manager #2 said if a resident consented to vaccine administration, any nurse could input the order for the vaccine in the electronic medical record for administration.During an interview on 12/10/25 at 10:51 A.M., the Director of Nursing (DON) said he is responsible for tracking and reporting resident vaccine administration. The DON said if a resident consents to influenza vaccination, the vaccine should be administered as soon as possible.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #2, to implement Enhanced Barrier Precautions; and2. For Resident #77, to perform hand hygiene during medication administration.Findings include: Review of the facility's policy titled Infection Control Guidelines for Nursing Procedures, revised 7/2024, indicated, but was not limited to, the following: -Enhance Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) -EBP is indicated for nursing home residents with: *Infection or colonization with an MDRO when Contact Precautions don't otherwise apply *Chronic wounds *Indwelling medical devices -PPE: Use of gown and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing -In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub: *Before preparing or handing medications Review of the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, indicated, but was not limited to, the following:- Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)- Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the CDC Enhanced Barrier Precautions sign indicated:-Everyone must clean their hands, including before entering and when leaving the room-Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care (any skin opening requiring a dressing). 1. Resident #2 was admitted to the facility in March 2025 with diagnoses including end stage renal disease. Review of Resident #2's Minimum Data Set (MDS) assessment, dated 9/5/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #2's medical record indicated the Resident had bilateral arteriovenous fistulas and a tunneled hemodialysis catheter in his/her right chest. Further review indicated the Resident returned from the hospital in November 2025 with a surgical wound on his/her right hip. Review of Resident #2's Care Plan failed to indicate the Resident required Enhanced Barrier Precautions. Review of Resident #2's Physician's Orders failed to include orders for Enhanced Barrier Precautions. On 12/8/25 at 7:57 A.M., the surveyor observed a CDC Enhanced Barrier Precautions sign posted outside of the Resident's room and a cart with personal protective equipment (PPE) was located beneath the sign. On 12/9/25 at 11:24 A.M., the surveyor observed Nurse #2 applying a dressing over Resident #2's right hip surgical incisions. CNA #1 was present and assisting in positioning the Resident. Nurse #2 and CNA #1 were not wearing a gown as indicated. The CDC Enhanced Barrier Precautions sign was posted outside of the Resident's room and PPE was located in a cart beneath the sign. During an interview on 12/9/25 at 11:29 A.M., Nurse #2 said Resident #2 required Enhanced Barrier Precautions and he should have been wearing a gown when performing wound care. During an interview on 12/9/25 at 3:30 P.M., the Assistant Director of Nursing (ADON) said Resident #2 required Enhanced Barrier Precautions due to his/her hemodialysis catheter and right hip wound. The ADON said Nurse #2 should have worn a gown when performing Resident #2's wound care. During an interview on 12/10/25 at 10:51 A.M., the Director of Nursing (DON) said Nurse #2 should have been implementing Enhanced Barrier Precautions and wearing a gown when performing Resident #2's wound care. 2. Review of the facility's policy titled Administering Medications, dated as revised 9/2024 indicated but was not limited to: - Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 12/9/25 at 5:00 P.M., the surveyor observed Nurse #8 prepare and administer medication to Resident #77. The surveyor observed: -Nurse #8 prepare the Resident #77's medication without performing hand hygiene prior to initiating medication preparation -At 5:05 P.M., Nurse #8 entered Resident #77's room. The surveyor observed an EBP sign at the door which indicated EBP were required for Resident #77. Nurse #8 entered the room and did not perform hand hygiene. -At 5:10 P.M., Nurse #8 exited Resident #77's room, and did not perform hand hygiene. -At 5:13 P.M., Nurse #8 returned to Resident #77s room and re-entered the room without performing hand hygiene. Nurse #8 continued with administering medications to Resident #77. -At 5:18 P.M., Nurse #8 exited Resident #77's room and returned to the medication cart. Nurse #8 did not perform hand hygiene upon completion of medication administration or when exiting Resident #77's room. During an interview on 12/9/25 at 5:30 P.M., Nurse #8 said she did not perform hand hygiene when preparing and administering Resident #77's medications, and thereafter. During an interview on 12/10/25 at 9:13 A.M., Unit Manager #2 said Nurse #8 should have performed hand hygiene. She said the nurse is familiar with the facility policy and did not follow it during her medication pass. During an interview on 12/10/25 at 12:40 P.M., the ADON said the nurse should have performed hand hygiene. She said when a room has a sign indicating EBP was required the precautions should be followed. She said the nurse did not follow the policy as required.

Based on interview and record review, the facility failed to ensure quality of care based on professional standards of practice for one Resident (#212), in a sample of three closed records. Specifically, the facility failed to ensure staff fully assessed Resident #212 who was on a blood thinner, had expressed pain, and had a bruise to the left hip, resulting in a delay in treatment. The Resident was later identified to have a fracture to the left hip and was subsequently sent to the hospital where he/she received a blood transfusion. The Resident was determined to not be a candidate for surgery and was admitted to a hospice house. Findings include: Resident #212 was admitted to the facility in September 2024 with diagnoses of atrial fibrillation (A-fib: irregular and often very rapid heart rhythm which can lead to blood clots in the heart), lower extremity cellulitis (bacterial infection that affects the deeper layers of the skin and surrounding tissue), and dementia. Review of the Minimum Data Set (MDS) assessment, dated 9/30/24, indicated Resident #212 scored 11 out of 15 on the Brief Interview for Mental Status, indicating he/she had moderate cognitive impairment. The MDS indicated Resident #212 was taking an anticoagulant (blood thinner). Review of the Nurse Practitioner (NP)'s Progress Note, dated 9/30/24, indicated Resident #212 had lower extremity edema (bilateral), the left leg cellulitis had resolved (last dose of antibiotic on 10/1/24), A-fib was being treated with Coumadin (blood thinner), and to continue to monitor. Review of the NP's Progress Note, dated 10/7/24, indicated Resident #212 had increased behaviors including exit seeking, paranoia and agitation, and increased swelling in the lower extremities with no pain. Review of the Nursing progress note indicated that on 10/11/24 Resident #212 was guarding his/her left knee and leg with facial grimacing and voicing pain when leg was moved. The Resident was seen by the NP and an x-ray of the knee and tibia/fibula (lower bones of the leg) were ordered. Review of the NP's Progress Note on 10/11/24 indicated the Resident was yelling in pain and would not allow the NP to move his/her leg and would grab their knee. Review of the x-ray results indicated there were no fractures for the knee or the tibia/fibula. Review of the NP's Progress Note, dated 10/14/24, indicated Resident #212 had lower extremity edema and for nurses to apply compression stockings. Review of a Nursing progress note, dated 10/15/24 at 3:11 P.M., indicated the Certified Nursing Assistants (CNAs) and Unit Manager found a large bruise to the left hip and left lateral side of the lower leg with deep purple color and faded green/yellowing color surrounding the left hip and going down the leg. A stat (immediate) x-ray was ordered. The x-ray results indicated Resident #212 had a fractured left hip and Resident #212 was sent to the hospital on [DATE]. During an interview on 11/6/24 at 10:20 A.M., CNA #4 said she was the assigned CNA for Resident #212 on the 7:00 A.M. to 3:00 P.M. shift when she worked. The CNA said she had worked 10/12/24, 10/13/24, and 10/14/24. She said the Resident had started to need additional assistance and she and CNA #5 helped Resident #212 transfer from the bed to a shower chair with a lift device (Sit to Stand) which was an increase in assistance for the Resident. She said on 10/14/24 (one day prior to the nursing note identifying the bruise) she was getting ready to give Resident #212 a shower when she saw a large bruise on the hip which was red and yellow. She said she had not seen the bruise the day prior (10/13/24). She said she told the nurse about the bruise. During an interview on 11/6/24 at 11:38 A.M., CNA #4 said she had told Nurse #6 about the bruise on the hip of Resident #212 and the Nurse said they were already aware of the bruise and they were handling it. During an interview on 11/6/24 at 10:24 A.M., CNA #5 said she was with CNA #4 on 10/14/24 when they saw the bruise. She said she was not the primary CNA for this Resident but had helped other CNAs and had not seen the bruise until 10/14/24 with CNA #4. Review of the activity of daily living documentation completed by the CNAs indicated Resident #212 received a shower on 10/14/24. During an interview on 11/6/24 at 10:52 A.M., Physical Therapist #1 said she had regularly been working with Resident #212 who had an increase in fatigue and being aggravated during the week of 10/7/24. She said she saw the bruise on 10/16/24 and the bruise had been there awhile because it had started to yellow and descend down the leg, which is usually what happens as it progresses. Review of the Medication Administration Record (MAR) included an order, dated 9/28/24, to monitor for side effects of anticoagulant medications such as unusual bleeding, excessive bleeding, excessive bruising, black/tarry stools: if symptoms observed notify MD/NP and document in a progress note; monitor every shift. Review of the Treatment Administration Record (TAR) included an order, dated 9/24/24, to complete a weekly skin check every Monday during the 7:00 A.M. to 3:00 P.M. shift. Review of the TAR indicated Nurse #6 signed off that a skin check was completed on 10/14/24. During an interview on 11/6/24 at 12:10 P.M., Nurse #6 said she was the assigned nurse for Resident #212 on 10/14/24. She said she remembered the CNAs telling her the Resident had a bruise but when she inquired about the lower extremity the Unit Manager and the NP had told her they had already done an x-ray (on 10/11/24). She said she did not do a complete skin check on the Resident or look at the hip. She said she looked at the lower part of the lower extremity and thought there was some discoloration including bruising and told the NP about the discoloration and that was why there was a note to use the compression stockings. Review of the medical record included a Weekly Skin Evaluation dated 10/14/24 and signed on 10/17/24 by Unit Manager #1. The Skin Evaluation failed to indicate any discoloration or bruising of the skin. During an interview on 11/6/24 at 4:10 P.M., Unit Manager #1 said she did not have time to enter skin checks as they were completed, so she could not be sure the exact day the skin check was completed for Resident #212, but maybe it was completed the day before the bruise was found. She said she and two CNAs had found the large bruise to the hip on 10/15/24 (over 24 hours after it was found by CNA #4). She said the bruising was on the hip, knee, and the lower part of the extremity and the coloring ranged from deep purple and areas of yellowing. She said no one had told her about the bruising on 10/14/24. She said the CNAs would not know who was on an anticoagulant (blood thinner) and who was at risk for bleeding, but that the CNAs should know to report all bruises to the nurse. She said Nurse #6 had not said anything about bruising on 10/14/24 and the nurse should have checked the skin based on the CNAs report of bruising. During an interview on 11/5/24 at 3:50 P.M., the NP said she had evaluated the Resident for leg pain on 10/11/24. She said the Resident was always evaluated with their clothes on and was always in the wheelchair. She said Resident #212 would not allow her to conduct range of motion and the Resident had been grabbing the lower part of their lower extremity. She said the Resident was on Coumadin and should have been monitored for bruising. She said no one had relayed to her that there was bruising anywhere on the body until 10/15/24. She said based on the presentation of the bruise on 10/15/24, the bruise had been there for at least a few days. She said, for residents on blood thinners, the identification of bruising needs to be presented to the physicians for them to get the full picture. She said, had the staff informed her of the bruise to the hip, she would have ordered the x-ray sooner and sent the Resident to the hospital sooner. She said she spoke with the Director of Nurses (DON) about ensuring bruises were reported and that unfortunately a hip fracture had been missed. During an interview on 11/6/24 at 11:45 A.M., the spouse of Resident #212 said she did not know about the bruise until 10/16/24 when the ambulance arrived to transfer the Resident to the hospital. She said the Resident was bruised all down the left leg and it was yellowing. She said when the Resident arrived at the hospital they had to do a blood transfusion. She said the hospital discussed complications that could arise if the Resident received surgery and the Resident was sent to a hospice house and had passed within days. During an interview on 11/6/24 at 4:40 P.M., the DON said the staff had not told him the bruise was seen on 10/14/24. He said the NP had discussed that staff needed to tell her about bruising, but since none of the staff had seen the bruise, he had not provided any education to the staff. Review of the hospital Discharge summary, dated [DATE], indicated Resident #212 arrived to the hospital on [DATE] with a hip fracture and old appearing ecchymosis (bruising) on the left hip that was yellow in color with swelling throughout the entire left lower extremity. The summary indicated the Resident presented with the following: hyperkalemia (too much potassium in the blood), anemia (noted as acute blood loss anemia (a blood disorder that occurs when the blood has a reduced ability to carry oxygen)) and an elevated INR (international normalized ratio, a blood test that measures how long it takes for blood to clot, higher INR indicates blood takes longer to clot). The summary indicated the following laboratory results: hemoglobin was 7.5 - low (a protein in red blood cells that carries oxygen from lungs which can be effected by bleeding), the potassium was 5.4 (high) (when cells are rapidly destroyed, their components, including potassium, move into the bloodstream), and an increase in INR to 3.6 (from 2.6 on 10/14/24). The summary indicated the hemoglobin continued to trend down and the Resident required a blood transfusion of 2 units on 10/17/24 and after further discussion with the family the Resident was transferred to a hospice house.

Based on observations, interviews and record review the facility failed to ensure the environment was free from accident hazards for Residents on the secure unit ([NAME]) and for two Residents (#105 and #79) in a total sample of 24 residents. Specifically, the facility failed: 1. To ensure hazardous items (bleach wipes, razors, medications) were not accessible to cognitively impaired residents on the secure unit; 2. For Resident #105, assessed at a high risk for elopement/wandering, to ensure the Resident was provided the indicated intervention of a wander guard; and 3. For Resident #79, to ensure that alcohol brought in by family was securely stored. Findings include: 1. During the entrance conference on 11/3/24 at 9:15 A.M., the Director of Nurses (DON) said the facility had a secure unit, the [NAME] (Alzheimer's Friendly Unit). On 11/4/24 at 11:11 A.M., the surveyor observed the bathroom/shower room on the unit with an unsecured cabinet with a container of bleach wipes. A child safety lock was observed hanging from one of the cabinet door handles, unlocked. During an interview on 11/6/24 at 10:10 A.M., Unit Manager #1 said the child safety lock on the cabinet in the shower room should be maintained in the locked position. She said residents should not have had access to bleach wipes and the bleach wipes were stored in the shower room so things could be wiped down after each resident use. She said the cabinet door had a child safety lock on it to prevent the residents from being able to get in it. On 11/4/24 at 11:15 A.M., the surveyor was able to open the key padded door to the soiled utility room without a code. The surveyor observed a sharps container with two shaving razors sticking out and easily accessible. On 11/4/24 at 3:01 P.M., the surveyor was able to open the unsecured door to the soiled utility room without a code and the razors continued to be protruding from the sharps container. On 11/5/24 at 10:22 A.M., the surveyor was able to open the unsecured door to the soiled utility room without a code and the razors continued to be protruding from the sharps container. During an interview on 11/5/24 at 1:45 P.M., Certified Nursing Assistant (CNA) #3 said she was not sure what the process was for the sharps container being emptied and the Unit Manager would know. During an interview on 11/5/24 at 1:48 P.M., Unit Manager #1 said the CNAs should tell the nursing staff when the sharps containers are full so that they are able to be moved to another room to be collected by the maintenance department. The surveyor and the Unit Manager went to the [NAME] soiled utility room. The Unit Manager said the keypad to the door should not allow access without the code and the room should be secure. She said the razors should not be sticking out of the sharps container and that the container was full. During an observation with interview on 11/5/24 at 2:45 P.M., the surveyor observed the medication cart on the [NAME] to be unlocked and unattended with three residents (two who were able to ambulate independently) sitting next to the medication cart. Nurse #4 returned to the medication cart at 2:50 P.M. and said the medication cart should have been locked. During an interview on 11/6/24 at 10:10 A.M., Unit Manager #1 said the medication carts should be locked whenever they were unattended for patient safety, especially on the [NAME] unit because the residents were cognitively impaired. She said everything should be locked and out of residents reach and should not be accessible. 2. Review of the facility's policy titled Wandering, Unsafe Resident, dated as revised in November 2017 indicated the following: -staff would identify residents who were at risk for harm because of unsafe wandering (including elopement) -staff would assess at-risk individuals for potential correctable risk factors related to unsafe wandering -resident's care plan would indicate the resident was at risk for elopement and interventions to try to maintain safety would be included Resident #105 was admitted to the facility in October 2024 with a diagnosis of dementia. Review of the Social Service Evaluation, dated 10/19/24, indicated Resident #105 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident #105 resided on the secure unit. Review of the care plans for Resident #105 indicated a risk for elopement. Review of the Hospital Discharge Summary indicated Resident #105 had left their home, was missing for two days and was found at a train station and had been placed on a one to one at the hospital for wandering. The discharge summary indicated the Resident would get disoriented and elope from home with three events of attempt for elopement. On 11/3/24 at 11:30 A.M., the surveyor observed Resident #105 dressed, groomed, ambulating independently and wearing a winter coat. The Resident was observed walking around the unit, with no purpose of destination. On 11/3/24 at 12:47 P.M., the surveyor observed Resident #105 walking around the unit and said out loud I'm thinking of leaving. On 11/4/24 at 9:08 A.M., the surveyor observed Resident #105 walking around the unit and wearing a large winter coat. On 11/4/24 at 11:08 A.M., the surveyor observed Resident #105 approach a housekeeper at the exit door for the unit. The Resident told the housekeeper that he/she lost their keys. The housekeeper exited the unit, and the Resident asked the surveyor what he/she should do without their keys. Review of the nursing admission assessment (Nursing Evaluation), dated 10/15/24, indicated Resident #105 was a high risk for elopement with an intervention for a wander alert (wander guard). Review of the nursing progress notes indicated the following: 10/15/24: Resident wanting to go home several times, pacing unit 10/16/24: wandering behavior 10/18/24: wanders unit; attempts made to pack clothes up into pillowcase and states he/she was going home During an interview on 11/4/24 at 3:20 P.M., Nurse #2 said the facility process for residents at risk for elopement was to add them to the Wander guard book. She said there was a book on each unit. The surveyor and the Nurse attempted to find the Wander guard book on the [NAME] unit and were unable to locate it. Review of the Wander guard book on the A unit included a picture and demographic information for residents from all units who were at risk for elopement. Review of the book failed to include information regarding Resident #105. There was an empty Wander guard book labeled [NAME] on the A unit. During an interview on 11/4/24 at 3:25 P.M., the Assistant Director of Nurses said the DON had been working on updating all of the Wander guard books for the units and she was not sure why the book labeled [NAME] was empty. During an interview on 11/4/24 at 3:40 P.M., Nurse #2 said Resident #105 was a newer admission to the facility who had confusion and would often ask to go home. The Nurse said the Resident did not have a wander guard but probably should. The Nurse verified the orders in the medical record and was unable to find an order to indicate the Resident had a wander guard. During an interview on 11/4/24 at 4:00 P.M., the DON said he had been re-organizing the Wander guard books and had needed to add all residents to the [NAME] unit book. He said the process was for each unit to have a Wander guard book that contained all facility residents who were at risk for elopement. He said all residents who were at risk for elopement had wander guards and if a newly admitted resident was at risk for elopement they were added to the book and provided a wander guard. He checked the Wander guard book and confirmed Resident #105 was not in the book. He requested to review the Resident record and follow up with the surveyor. During an interview on 11/4/24 at 4:35 P.M., the DON said the nurse who had completed the admission assessment might have thought the Resident was at risk for elopement, but as of this time, the Resident had not attempted to go out of the doors. He said the interdisciplinary team (IDT) had not been notified the Resident was at risk for elopement and a wander guard had not been initiated. During an interview on 11/5/24 at 8:38 A.M., the DON said the nurse who had completed the admission assessment should have completed the intervention of a wander guard. 49424 3. Resident #79 was admitted to the facility in September 2022 with diagnoses including cerebral infarction, insomnia, and Type II Diabetes. Review of the Minimum Data Set (MDS) assessment, dated 10/3/24, indicated Resident #79 was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an interview with an observation on 11/3/24 at 10:37 A.M., the surveyor observed that Resident #79 had two brown paper bags of alcohol visible on his/her nightstand and windowsill. The Resident said he/she had a doctor's order for four ounces every night because it helps him/her sleep. The Resident said the nurse was informed of the alcohol being in his/her room. Resident #79 said it was delivered by family on 11/2/24 at 2:00 P.M. The surveyor observed wine (two one-liter bottles, one four pack, and two four packs). In the bag there were a total of 23 6-ounce bottles. The Resident said he/she received one 6-ounce bottle of red wine from the bag last evening. On 11/3/24 at 12:30 P.M., the surveyor observed CNA #2 tell Nurse #9 that Resident #79 was asking for the nurse to take the wine and secure it. CNA #2 said Resident #79 wanted me to remind you to not forget about it. Nurse #2 verbalized acknowledgement to CNA #2. On 11/3/24 at 1:32 P.M., the surveyor observed Resident #79's roommate walking in the room and talking with Resident #79. Further investigation indicated Resident #79's roommate had a history of substance use disorder. During an observation with an interview on 11/3/24 at 1:40 P.M., Resident #79 said he/she told Nurse #10 and CNA #2 to take the wine in his/her room and secure it in the medication room. Resident #79 pointed to the bags and bottles of wine in the room. Resident #79 said Nurse #9 was aware of the alcohol in the room and he provided him/her with their nightly wine from the bag last evening. During an interview with an observation on 11/3/24 3:01 P.M., Resident #79 said Nurse #9 was looking for a spot to put the wine but since there was more than usual, he wouldn't be able to put in all in the medication cart. The surveyor observed two one-liter bottles of wine on the Resident's windowsill at the following times: -11/04/24 at 07:11 A.M. -11/04/24 at 09:00 A.M. -11/04/24 at 12:30 P.M. -11/04/24 at 03:50 P.M. -11/05/24 at 07:20 A.M. During an interview on 11/4/24 at 10:59 A.M., Resident #79's family member said he wasn't sure why they let the Resident keep the alcohol in their room which was brought in on Saturday. During an interview on 11/5/24 at 7:21 A.M., Nurse #3 said alcohol should not be kept with the residents in their room for safety reasons. He said alcohol requires a physician's order and should be secured in the medication cart or secured in the medication storage room. During an interview on 11/5/24 at 7:25 A.M., CNA #1 said the nurse is the only person that can give a resident alcohol like beer or wine. She said it cannot be kept in their room. During an interview with observation on 11/5/24 at 7:45 A.M. with Unit Manager #2 and Resident #79, Unit Manager #2 said the family was responsible for providing the alcohol to Resident #79. She said the process should be the nurse counts how much is brought in and it is taken immediately and secured in the medication room. She said there should be no alcohol in any resident's room. The Unit Manager asked the Resident if there was any additional wine and the Resident said he/she had told the nurse there were two bigger bottles after he took the smaller ones. Unit Manager #2 said alcohol was treated like medication with specific orders and nursing needed to know how much was given and at what time. She said there are risks with keeping alcohol in the room such as the Resident could drink an unknown amount, or another resident could drink the alcohol. She said she was aware the Resident's roommate had a history of substance use disorder. She said there should be a nursing note which included the amount of alcohol brought in by family and when it was brought in. During an interview on 11/6/24 at 8:12 A.M., Nurse #10 said he took the small bottles of wine out of the Resident's room and secured them in the medication cart at 7:30 P.M on 11/3/24. He said the resident did not report how much wine was brought in and he did not write a note regarding the securing of the alcohol. He said he was aware that residents should not have alcohol in their room. During an interview on 11/5/24 at 9:13 A.M., the DON said alcohol should not be left unsecured as residents could drink it without supervision. He said the process was not followed and the alcohol should be secured because it is considered a medication and was documented on the Medication Administration Record (MAR). He said a licensed nurse was the only person who can provide alcohol to a resident. During an interview on 11/5/24 at 10:01 A.M., the Regional Nurse said the expectation was all alcohol should be secured in the medication room and there should be a physician's order to give it. There should be no instance where there are bottles of alcohol unsecured at the bedside.

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 food items were properly dated and stored in the main kitchen and kitchenettes; 2. Ensure four of four ice machines were maintained in a clean and sanitary condition; and 3. Ensure one of three unit kitchenettes was maintained in a clean and sanitary condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Food and Supply Storage, revised 06/2018, indicated but was not limited to: Policy: Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes. 1. General guidelines: a. Storerooms are well-lit, adequately ventilated, clean and dry; b. Storeroom walls and floors are solid, cleanable, in good repair and rodent proof. 2. Labeling and rotating food: a. Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. 1) Follow recommendations from the manufacturer when indicated on the product for storage time and storage location; 2) Follow city, county, or state food storage guidelines. Review of the facility's policy titled Ice Production and Handling, revised 06/2018, indicated but was not limited to: Policy: Ice is produced and handled in a manner to minimize contamination. Guidelines: f. Keep equipment clean, including draining, cleaning, and sanitizing internal components of the ice machine as needed and according to the manufacturer's specifications, cleaning schedules, and preventative maintenance schedules. This may include but is not limited to: -removing the build-up of mineral scale from the ice machine's water systems and sensors; -sanitizing the ice machine's water system and ice storage bin or dispenser. 1. On 11/3/24 at 7:57 A.M., the surveyor observed the following in the main kitchen: -one opened container of thickened apple juice dated as opened 9/9, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -two opened containers of thickened dairy drink with no opened date, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened orange juice dated 11/15, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. On 11/3/24 at 8:55 A.M., the surveyor observed the following in the Unit A kitchenette: -one opened container of thickened apple juice dated as opened 9/20, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened cranberry juice dated as opened 10/8, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. On 11/3/24 at 9:22 A.M., the surveyor observed the following in the Unit C kitchenette: -one opened container of thickened dairy drink dated as opened 10/18, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened dairy drink dated as opened 10/17, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened lemon water with no opened date, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. On 11/5/24 at 11:40 A.M., the surveyor observed the following in the main kitchen: -two opened containers of thickened juice with no opened date, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened dairy drink with no opened date, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. -one opened container of thickened lemon water dated 10/16-11/16, manufacturer label stated: after opening, may be kept up to seven days under refrigeration. During an interview on 11/6/24 at 10:29 A.M., Nurse #10 said any containers of thickened liquids must be dated when opened. During an interview on 11/6/24 at 2:12 P.M. with the Food Service Director (FSD) and the Corporate FSD, the FSD said he expected all thickened liquids to be dated with the opened date and discarded seven days after opening and for staff to follow the manufacturer's instruction to discard containers of thickened liquids after seven days of opening. 2. The surveyor made the following observations: -11/3/24 at 7:57 A.M.: Main kitchen ice machine with orange-brown growth on interior flap and observed condensation dripping from the orange-brown growth onto the ice; vendor sticker indicated 7/24; -11/3/24 at 9:03 A.M.: Unit A kitchenette ice machine with several areas of dark spots in the interior, specifically one interior component had black growth at the bottom and water was observed dripping from black growth onto the ice; vendor sticker indicated 7/24; -11/3/24 at 9:22 A.M.: Unit C kitchenette ice machine with an internal component (white in color) that had areas of orange growth; observation of orange growth that had transferred from the white component to another internal component below it; ice was just inches below both components; vendor sticker indicated 7/24. On 11/6/24 at 2:47 P.M., the FSD, the Director of Maintenance (DOM) and the surveyor observed orange-brown colored growth on interior components of main kitchen the ice machine, with water dripping from the growth onto the ice. The FSD and the DOM said all ice machines are serviced and cleaned every three months by a vendor and the vendor had written the last date of service on the ice machine which read 7/24. The FSD and the DOM said the ice machines in the main kitchen and on the resident units are not cleaned by the facility and are only cleaned by the vendor every three months. During an interview on 11/6/24 at 2:52 P.M., the FSD observed the Unit A ice machine with the surveyor and observed several black splotches in the interior. The FSD wiped the splotches with a paper towel to identify if it was a stain or growth. The black splotches were removed by the paper towel. During an interview on 11/6/24 at 2:58 P.M., the Administrator said the ice machines are cleaned every three months by a vendor and there was no cleaning schedule for the facility to clean the machines between vendor visits. The Administrator observed the growth in the ice machine and said there should be no growth inside the ice machines. During an interview on 11/6/24 at 3:10 P.M., the FSD observed the Unit C ice machine with the surveyor and observed several black colored splotches on the interior of the ice machine. The FSD wiped the black splotches with a napkin to determine if they were growth or discoloration. The black splotches were removed by the paper towel. During an interview on 11/6/24 at 3:20 P.M., the FSD observed the Unit B ice machine with the surveyor and observed black, brown, yellowish growth littered throughout the internal compartment and components. The FSD said the Unit B ice machine should be free of any growth. 3. On 11/3/24 at 8:57 A.M., the surveyor observed the following in the Unit A kitchenette: -An open floor drain used as drainage for the ice machine; -The open floor located next to ice machine and toaster; -Black and brown growth on the drain grate; -Greenish-white slimy substance on drain grate; -Black growth around the floor drain grate; -Black growth between floor tiles around and adjacent to the floor drain; -Black growth where floor meets wall, adjacent to the floor drain; -Extremely warm air temperature in the kitchenette; -Dozens of dead drain flies on floor next to drain. On 11/6/24 at 12:25 P.M., the surveyor observed the following in the Unit A kitchenette: -The open floor located next to ice machine and toaster; -Black and brown growth on the drain grate; -Greenish-white slimy substance on drain grate; -Black growth around the floor drain grate, which the surveyor could easily wipe away with a napkin; -Black growth between floor tiles around and adjacent to the floor drain; -Black growth where floor meets wall, adjacent to the floor drain; -Extremely warm air temperature in the kitchenette; -Damp smell close to the drain. During an interview on 11/6/24 at 3:00 P.M., the Administrator said the ice machine used to be over the drain and the ice machine was moved recently as to not cover the drain. The Administrator said the drain was also replaced with a larger drain to better meet the drainage needs of the ice machine. The DOM and Administrator observed the open floor drain and said it needed to be cleaned and the tile and area surrounding the drain needed to be replaced in order to remove the black growth. The Administrator said the floor in the kitchenette should be clean and clear of any growth.

Based on observations, interviews, and records reviewed, the facility failed to provide pain management interventions for one Resident (#105) with tooth pain, out of 24 sampled residents. Specifically, for Resident #105, the facility failed to provide prescribed, as needed, pain relief for tooth pain. Findings include: Resident #105 was admitted to the facility in October 2024 with diagnoses of toothache and aphthous ulcer (or canker sore- a small shallow ulcer that occurs on the lining of the mouth). Review of the Hospital Discharge Summary indicated Resident #105 had a toothache and aphthous ulcer. The discharge summary indicated the Resident complained of right lower tooth pain, dental caries (cavities) noted and had a aphthous ulcer on the left upper palate. The plan was to continue to monitor, use Tylenol, Lidocaine mouthwash, home benzocaine ointment for pain control and a referral for outpatient dental at discharge. Review of the care plans indicated Resident #105 had dental caries and to refer to the dentist as needed. Review of the Nurse Practitioner's Progress Note, dated 10/16/24, indicated Resident #105 frequently complained of right lower tooth pain and to continue Tylenol as needed and a dental referral was needed. Review of the nursing progress notes indicated the following: 10/18/24: Tylenol given for complaint of pain to right gum area 10/18/24: Seen by physician with new order to have dental evaluation; form faxed to in-house consultant dentist 10/23/24: Resident with complaint of mouth pain, Tylenol given, referral sent this week to in-house consultant dentist, new order for Orajel (topical treatment used to relieve mouth pain) four times per day as needed 10/24/24: Resident with complaint of mouth pain to right lower jaw, visible swelling, tender to touch, Tylenol given 10/25/24: given Tylenol for complaint of toothache, right lower jaw 10/30/24: complaining of right sided facial pain, right cheek edematous, given Tylenol 10/31/24: Resident complained of gum/mouth pain, new order for Ibuprofen 400 milligrams (mg) every eight hours as needed 11/1/24: Resident complains of mouth pain Review of the Nurse Practitioner Progress Note, dated 11/1/24, indicated the Resident had tooth/gum pain with a new order for Lidocaine Viscous 2% 15 milliliters swish and spit (used to relieve mouth pain) every four hours as needed, to continue Orajel, continue Tylenol and Ibuprofen as needed and the referral to the dentist was pending. On 11/3/24 at 11:30 A.M., Resident #105 approached the surveyor and said he/she had a toothache. The surveyor brought the Resident to Nurse #1. The surveyor observed Resident #105 tell Nurse #1 that he/she had a toothache, the nurse asked the Resident to demonstrate where the toothache was, the Resident opened their mouth and pointed, the Nurse responded oh, you have a black tooth. On 11/3/24 at 1:15 P.M., the surveyor observed Resident #105 walking on the unit with a tube of toothpaste in his/her hand. The Resident was observed placing toothpaste on his/her finger and rubbing the right inside of their mouth. On 11/4/24 at 11:00 A.M., the surveyor observed Resident #105 walking down the hall with his/her fingers in the right side of their mouth. On 11/4/24 at 2:34 P.M., the surveyor observed Resident #105 tell another resident My tooth is killing me. Review of the Medication Administration Record (MAR) indicated Orajel- give one application by mouth every 6 hours as needed for pain, was ordered on 10/23/24. The MAR indicated as of 11/4/24 (13 days) the Orajel was not administered to Resident #105. Review of the MAR indicated an order for Ibuprofen 400 mg every 8 hours for pain was implemented on 10/31/24. The MAR indicated as of 11/4/24 (5 days) the Ibuprofen was not administered to Resident #105. Review of the MAR indicated Lidocaine Viscous 2%, give 15 ml every four hours as needed for mouth pain swish and spit was ordered on 11/1/24. The MAR indicated as of 11/4/24 the Lidocaine Viscous was not administered to Resident #105. Review of the MAR on 11/4/24 indicated Tylenol 650 mg was last administered on 10/30/24 (6 days prior). The MAR failed to indicate any Tylenol, Ibuprofen, Orajel or Lidocaine Viscous were used from 10/31 through 11/4/24, including nothing administered on 11/3/24 when the Resident complained of tooth pain to the nurse. During an interview on 11/4/24 at 3:55 P.M., Nurse #1 said Resident #105 complained of tooth pain on 11/3/24 and she had given the Resident Tylenol 650 mg. She said she had not documented this in a nursing progress note. She said she had not documented this on the MAR because all residents had standing order for as needed Tylenol, so she did not think she needed to document this. She said the Tylenol did not work on 11/3/24 because the Resident kept coming back to the nurse and complaining of pain. She said she was unable to find the Lidocaine Viscous or the Orajel and had not administered any Ibuprofen. During an interview on 11/5/24 at 10:30 A.M., Nurse #4 said she worked at the facility one time per week and was aware the Resident had tooth pain. She said she knew there was an order for Orajel, but she had not been able to find it. She said she did not know anything about the Lidocaine Viscous. The surveyor and the nurse observed the medication cart. The nurse was unable to locate either pain relief medication. The surveyor was able to find a box for the Lidocaine Viscous with the Resident's name on it. The nurse said she did not know this was in the medication cart as the bottle was inside a box and not distinguished as a liquid. During an interview on 11/5/24 at 10:35 A.M., Unit Manager #1 said the Orajel should have been in the medication cart. Unit Manager #1 checked the medication cart and was unable to locate the Orajel. During an interview on 11/5/24 at 10:50 A.M., Unit Manager #1 said the Lidocaine was delivered to the facility on [DATE] at 2:57 A.M. so she was not sure why it had not been administered to Resident #105. She said she was not sure why Nurse #1 had been unable to find it on 11/3/24 because it was available in the medication cart. She said the nurses should be reading the orders for as needed medications and administering if the Resident was complaining of pain.

Based on interview and record review, the facility failed to assess a history of trauma and failed to assess for triggers to avoid potential re-traumatization for one Resident (#105) with a history of trauma, out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as revised in October 2019, indicated the following: -as part of the comprehensive assessment, identify history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Resident #105 was admitted to the facility in October 2024 with diagnoses of dementia, post-traumatic stress disorder (PTSD) and poly substance use disorder (PSUD). Review of the Social Service Evaluation, dated 10/19/24, indicated Resident #105 scored 4 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. Review of the Hospital Discharge Summary indicated Resident #105 had a diagnosis of PTSD. Review of the medical record included the diagnosis of PTSD. Review of the Social Service Evaluation, dated 10/19/24, indicated the Resident had not identified any trauma and a trauma care plan was not initiated. Review of the Behavioral Health Group note, dated 10/21/24, indicated Resident #105 had a diagnosis of PTSD, denied any trauma history and that Resident was a poor historian. The note indicated it was unclear where the PTSD diagnosis originated. During an interview on 11/5/24 at 10:45 A.M., Social Worker #1 said she had not completed the Social Service Evaluation for Resident #105. She said following the surveyor inquiry she reviewed the record and Resident #105 did have a diagnosis of PTSD and she was not sure why this was not reflected on the evaluation. She said the Resident should have been assessed for the trauma history and any triggers. During an interview on 11/6/24 at 8:00 A.M., Social Worker #2 said she had completed the evaluation for Resident #105, and she had not seen the diagnosis of PTSD. She said she did not review the hospital discharge paperwork for residents as this was clinical information and as the Social Worker she did not review clinical information. She said she had spoken with the Resident on 10/19/24 and had called the family as the Resident was asking to leave but had not asked the family about any history of trauma.

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#412), out of 24 sampled residents. Specifically, the facility failed to assess and monitor the Resident's left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) site. Findings include: Review of the facility's policy titled Hemodialysis Access Care, revised November 2017, indicated but was not limited to the following: Care of AVFs (arterio-venous fistula, dialysis access created by surgically connecting an artery and a vein) and AVGs (arterio-venous graft, a synthetic or animal-derived tubing to connect the artery and vein) -Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). -Do not use the access site arm to take blood samples, administer IV fluids or give injections. -Do not use the access arm to take blood pressure. Check the patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. Care Immediately Following Dialysis Treatment -The dressing change is done in the dialysis center post-treatment. -If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. Documentation The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis. Resident #412 was admitted to the facility in September 2024 with diagnoses including dependence on renal dialysis and end stage renal disease (ESRD). Review of Resident #412's Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS indicated Resident #412 received dialysis treatment. Review of Resident #412's current Physician's Orders indicated the Resident had dialysis three times weekly. On 11/4/24 at 12:38 P.M., the surveyor observed Resident #412's left arm AV fistula site, which was open to air. Review of Resident #412's Care Plan indicated but was not limited to the following: Focus: [Resident] needs dialysis r/t (related to) diagnosis of ESRD Intervention: -Monitor/document/report PRN any s/sx (signs/symptoms) of infection to access site: Redness, swelling, warmth or drainage. -Monitor/document/report PRN for s/sx of the following: Bleeding, hemorrhage, bacteremia, septic shock. -Protect access site from injury. Site: Right Arm; Avoid constriction on affected arm. No BP on limb with shunt/CV (central venous) dialysis catheter. Focus: Potential for complications related to hemodialysis for diagnosis of end stage renal failure Interventions: -Check shunt site for s/s (signs/symptoms) infection, pain, or bleeding daily and PRN (as needed) -Monitor shunt site by palpating for thrill & auscultating for bruit daily. Notify physician of absence of thrill or bruit. -Protect access site from injury. Site: [blank] -Avoid constriction on affected arm, such as carrying purse and constrictive clothing ? no BP (blood pressure) on limb with shunt/CV dialysis catheter Resident #412's Care Plan failed to indicate the correct location of the Resident's AV fistula and care of the access site. Further review of the Physician's Orders indicated but were not limited to the following: -Dialysis log vital signs and weight every Tue, Thu, Sat for dialysis monitoring (10/28/24) The Physician's Orders failed to indicate orders for the care of the Resident's AV fistula. Review of Resident #412's Progress Notes failed to indicate the facility routinely monitored and/or provided care for the Resident's left AV fistula. Further review of the Progress Notes indicated that on the following dates, the Resident's blood pressure was obtained from the left arm, the arm in which the Resident's AV fistula is located: -10/10/24, -10/11/24, -10/13/24, -10/16/24, -10/18/24, -10/20/24, -10/21/24, -10/22/24, -10/23/24, -10/24/24, -10/25/24, -10/26/24, -10/29/24, -10/30/24, -10/31/24, -11/1/24, -11/2/24, and -11/3/24 During an interview on 11/4/24 at 12:38 P.M., Resident #412 said that he/she has an AV fistula in his/her left arm. The Resident said that the staff at the dialysis center apply a bandage to his/her access sites on his/her left arm when he/she finishes his/her dialysis treatment and that he/she removes the bandage himself/herself the next day. The Resident said that the nurses at the facility do not check the AV fistula site or check the dressing. During an interview on 11/4/24 at 12:45 P.M., Unit Manager #1 said Resident #412 should have orders for care and monitoring of the AV fistula site and orders for removal/care of the dressing on the access sites. During an interview on 11/6/24 at 12:30 P.M., the Director of Nursing said that Resident #412 should have had a physician's order in place to monitor the dialysis access site and for dressing care and the facility's nurses should be monitoring and caring for the Resident's access site.

Based on interview and record review, the facility failed to act upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendation to consider obtaining a lab to monitor the efficacy of Levothyroxine (a hormone used to treat thyroid disorder). Findings include: Review of the facility's policy titled Medication Regimen Review, dated August 2020, indicated but was not limited to: -Recommendations are acted upon and documented by the facility staff and/or the prescriber -The prescriber accepts and acts upon recommendations or rejects and provides an explanation for disagreeing Resident #6 was admitted to the facility in August 2022 with diagnoses which included thyroid disorder. Review of Resident #6's medical record indicated he/she was seen by the Consultant Pharmacist in January 2024 and recommendations were made. The surveyor was unable to locate the January 2024 Consultant Pharmacist's recommendation in Resident #6's record. After inquiry, the facility provided Resident #6's January 2024 Consultant Pharmacist Recommendation to Prescriber Form. The document indicated but was not limited to: -Resident #6 was receiving a medication that may benefit from laboratory monitoring -The pharmacist recommended a lab be drawn on the next convenient day and then annually thereafter -The physician/prescriber response section was blank During an interview on 11/6/24 at 3:01 P.M., Unit Manager #2 said the Director of Nurses (DON) received the monthly pharmacist recommendations and distributed them to the prescribers. During an interview on 11/6/24 at 3:03 P.M., the DON said the monthly pharmacy recommendations should be reviewed by the prescriber and evidence should be maintained in the resident's medical record. The DON said the facility had no evidence that Resident #66's January recommendations were reviewed by the prescriber. During an interview on 11/6/24 at 2:38 P.M., the Administrator said the facility should follow the policy and ensure pharmacy recommendations were reviewed.

Based on observations, interviews, and records reviewed, the facility failed to provide timely dental services for one Resident (#105), of 24 sampled residents. Specifically, for Resident #105, the facility failed to initiate a timely dental appointment for tooth pain. Findings include: Review of the facility's policy titled Dental Services, dated as revised November 2017, indicated but was not limited to: -Routine and 24-hour emergency dental services are provided to residents through a contract agreement, referral to the resident's personal dentist, referral to a community dentist or referral to other health care organizations that provide dental services. DEFINITIONS for S483.55(b) [F791] Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Resident #105 was admitted to the facility in October 2024 with a diagnosis of dementia. Review of the Hospital Discharge Summary indicated Resident #105 had a toothache and an aphthous ulcer (or canker sore- a small shallow ulcer that occurs on the lining of the mouth). The discharge summary indicated the Resident complained of right lower tooth pain, dental caries (cavities) noted and had a aphthous ulcer on the left upper palate. The plan was to continue to monitor, use Tylenol, Lidocaine mouthwash, home benzocaine ointment for pain control and a referral for outpatient dental at discharge. Review of the care plans indicated Resident #105 had dental caries and to refer to the dentist as needed. Review of the Nurse Practitioner's (NP) Progress Note, dated 10/16/24, indicated Resident #105 frequently complained of right lower tooth pain and to continue Tylenol as needed and a dental referral was needed. Review of the nursing progress notes indicated the following: 10/18/24: Tylenol given for complaint of pain to right gum area 10/18/24: Seen by physician with new order to have dental evaluation; form faxed to in-house consultant dentist 10/23/24: Resident with complaint of mouth pain, Tylenol given, referral sent this week to in house consultant dentist, new order for Orajel (topical treatment used to relieve mouth pain) four times per day as needed 10/24/24: Resident with complaint of mouth pain to right lower jaw, visible swelling, tender to touch, Tylenol given 10/25/24: given Tylenol for complaint of toothache, right lower jaw 10/30/24: complaining of right sided facial pain, right cheek edematous, given Tylenol 10/31/24: Resident complained of gum/mouth pain, new order for Ibuprofen 400 milligrams (mg) every eight hours as needed 11/1/24: Resident complains of mouth pain Review of the NP's Progress Note, dated 11/1/24, indicated the Resident had tooth/gum pain with a new order for Lidocaine viscous 2% 15 milliliters swish and spit every four hours as needed, to continue Orajel, continue Tylenol and Ibuprofen as needed and the referral to the dentist was pending. On 11/3/24 at 11:30 A.M., Resident #105 approached the surveyor and said he/she had a toothache. The surveyor brought the Resident to Nurse #1. The surveyor observed Resident #105 tell Nurse #1 that he/she had a toothache, the nurse asked the Resident to demonstrate where the toothache was, the Resident opened their mouth and pointed, the Nurse responded oh, you have a black tooth. During an interview on 11/4/24 at 12:25 P.M., the Director of Nurses (DON) said he was responsible for coordinating the in-house consultant dental services. He said the dentist had visited the facility on 9/18/24 (prior to the Resident's admission) and there was no schedule for the next visit at this time. He said the consultant dental services would tell the facility when they were coming, usually every 60 to 90 days. He said there was a community dentist in the area who the facility could refer residents to and there were no concerns with wait times for appointments. When the surveyor inquired about a dental appointment for Resident #105 the DON said, They just got here. He said he would have to review what the plan was for the Resident to see a dentist and if the Resident had been referred to a community dentist since the in-house consultant dental services had no scheduled appointment. During an interview on 11/4/24 at 1:58 P.M., the DON said the nursing staff had sent a referral to the in-house consultant dental services on 10/18/24 and at this time there was no indication of when they would come to the facility. He said following the surveyor inquiry the facility made an appointment with a community dentist for Resident #105 to be seen on 11/7/24, three weeks after the Resident was admitted with a plan for a referral to the dentist. During an interview on 11/5/24 at 10:36 A.M., Unit Manager #1 said she had spoken to the family of Resident #105 on the previous day (11/4/24). She said the family identified that Resident #105 had previously seen a dentist for the ill-fitting dentures which may be causing aphthous ulcer and the family was okay with a second opinion and for a dentist to address the separate issue of the toothache.

Based on record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#66), out of 24 sampled residents. Findings include: Resident #66 was admitted to the facility in [DATE] with diagnoses which included psychosis, major depressive disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #66 had a Guardian and received antipsychotic medications on a routine basis. Review of the medical record indicated Resident #66 was found to be incapable of taking care of him/herself by reason of mental illness and Guardianship was appointed on [DATE] by the Commonwealth of Massachusetts Probate and Family Court. Subsequent review of the medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via a [NAME] Treatment Plan, which expired on [DATE] at 9:00 A.M. Review of Resident #66's Physician's Orders indicated but was not limited to: -Zyprexa (antipsychotic) 2.5 milligrams (mg) by mouth one time daily, dated [DATE] Review of the September, October, and [DATE] Medication Administration Records (MAR) indicated Resident #66 was administered Zyprexa as ordered. During an interview on [DATE] at 1:59 P.M., Nurse #7 said Resident #66 had a Guardian and a [NAME]. Nurse #7 said Resident #66 received Zyprexa daily. During an interview on [DATE] at 2:12 P.M., Unit Manager #2 said Resident #66 had a [NAME] for the administration of Zyprexa. Unit Manager #2 said she was not sure where Resident #66 stood with his [NAME] renewal at this time, because the Social Service Department handled the [NAME] renewals. During an interview on [DATE] at 12:05 P.M., Social Worker #1 said residents with a Guardian should have an active [NAME] Treatment Plan in place when they are receiving antipsychotic medications. Social Worker #1 said the facility was in the process of renewing Resident #66's [NAME] Treatment Plan, but at this time there was no court date scheduled. During an interview on [DATE] at 12:53 P.M., Social Worker #1 said the facility sent the required paperwork to the facility lawyer to be processed on [DATE] and then again in May. Social Worker #1 said, in August, the facility lawyer told the facility the required documentation needed to be resubmitted because it was no longer valid. Social Worker #1 said the facility psych provider restarted the required paperwork and it had been resubmitted at that time. Social Worker #1 said on [DATE] she contacted the facility lawyer for an update but had not received one at this time. Social Worker #1 said the court hearing had not been scheduled. During an interview on [DATE] at 4:32 P.M., the Administrator said [NAME] Treatment Plans should be renewed annually when a resident has a Guardian and is receiving antipsychotic medications. The Administrator said the facility had some issues with getting required documentation completed for the renewal of Resident #66's [NAME] Treatment Plan but was working with the facility lawyer to get it done. On [DATE] at 12:43 P.M., the surveyor called the facility lawyer and left a message. As of the end of survey, on [DATE], the survey team did not receive any additional evidence that the required paperwork for a [NAME] Treatment Plan had been completed and submitted to the courts.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#33), out of 24 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address his/her cancer treatment. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated as revised January 2024, indicated but was not limited to: -A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. -Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's conditions change. Resident #33 was admitted to the facility in March 2018 with diagnoses which included lung and rectal cancer. Review of the Minimum Data Set (MDS) assessment, dated 9/19/24, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #33's medical record indicated he/she was undergoing chemotherapy for treatment of lung cancer. Review of Resident #33's care plan failed to indicate a care plan for his/her cancer and chemotherapy had been developed. During an interview on 11/4/24 at 2:47 P.M., Nurse #7 said Resident #33 had lung and rectal cancer and was followed by the cancer center. Nurse #7 said Resident #33 was receiving chemotherapy to treat the cancer. During an interview on 11/5/24 at 9:44 A.M., Nurse #7 said care plans should be updated with significant changes to a residents' treatment plan or medication orders. During an interview on 11/6/24 at 1:23 P.M., Nurse #8 said care plans were managed by the facility management team but should be updated as the treatment plans change and should reflect the resident's current status. During an interview on 11/6/24 at 11:45 A.M., Unit Manager #2 said care plans should be comprehensive and reflect the resident's care and current treatment plans. Unit Manager #2 said Resident #33 did not have a care plan for his/her cancer treatment, but he/she probably should especially because of the potential side effects. During an interview on 11/6/24 at 3:03 P.M., the Director of Nurses (DON) said care plans should be updated and reflect the resident's treatment plans. The DON said there should have been a care plan for Resident #33's cancer and cancer treatments.

Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for two Residents (#33 and #18), of 24 sampled residents. Specifically, the facility failed: 1. For Resident #33, to ensure his/her Dexamethasone (a corticosteroid to treat/prevent inflammation) orders were accurately transcribed, administered, and documented; and 2. For Resident #18, to administer Propranolol (a medication that affects the heart and circulation and is used to treat conditions such as heart rhythm disorders and other heart or circulatory conditions) in accordance with prescriber orders. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Administering Medications, dated as revised September 2024, indicated but was not limited to: -Medications are administered in accordance with prescriber orders -The individual administering the medication records the administration in the resident's Medication Administration Record (MAR) Review of the facility's policy titled Medication and Treatment Orders, dated as revised September 2024, indicated but was not limited to: -All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order 1. Resident #33 was admitted to the facility in March 2018 with diagnoses which included lung and rectal cancer. Review of the Minimum Data Set (MDS) assessment, dated 9/19/24, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #33's Physician's Orders indicated but were not limited to: -Dexamethasone 4 milligrams (mg) by mouth every 12 hours as needed for anti-inflammatory, 10/21/24 - 11/5/24 -Dexamethasone 4 mg by mouth two times per day for anti-inflammatory for one day, 10/30/24 Review of Resident #33's Consultation/Clinic Referral, dated 10/21/24, indicated but was not limited to: -start Dexamethasone 4 mg twice daily the day before, the day of, and the day after chemotherapy Review of Resident #33's Cancer Institute After Visit Summary, dated 10/22/24, indicated he/she had an upcoming appointment for chemotherapy on 10/29/24. Review of Resident #33's October Medication Administration Record (MAR) failed to indicate he/she had received Dexamethasone 4 mg twice daily on 10/28/24 or 10/29/24. Review of Resident #33's Nurse's Note, dated 10/29/24, indicated the Cancer Institute called and informed the nurse that Resident #33 should receive Dexamethasone 4 mg twice daily the day before, the day of, and the day after chemotherapy. Further review of Resident #33's Nurse's Note, dated 10/29/24, indicated Resident #33's had a new order for Dexamethasone 4 mg twice a day to be administered on 10/30/24. Review of Resident #33's Cancer Institute After Visit Summary, dated 10/29/24, indicated he/she had an upcoming appointment for chemotherapy on 11/5/24. On 11/5/24 at 12:30 P.M., the surveyor reviewed Resident #33's November MAR which failed to indicate he/she had received Dexamethasone 4 mg twice daily on 11/4/24 and had not received any doses on 11/5/24. During an interview on 11/5/24 at 1:59 P.M., Nurse #7 said Resident #33 had chemotherapy today. Nurse #7 said he/she had received his/her Dexamethasone on 11/4/24 and 11/5/24 but he did not sign the medication off and did not document the administration in the MAR. During an interview on 11/5/24 at 2:12 P.M., Unit Manager #2 said Resident #33 should have received Dexamethasone 4 mg twice daily on 10/28/24, 10/29/24, 10/30/24, 11/4/24 and a dose that morning. Unit Manager #2 said the Resident should have received nine doses of Dexamethasone thus far. Unit Manager #2 and the surveyor reviewed the Dexamethasone card and only six doses were missing. Unit Manager #2 said the facility would not have had anywhere else to get the medication so doses may have been missed. During an interview on 11/5/24 at 2:32 P.M., Unit Manager #2 said she reviewed Resident #33's medical record and the six administered doses of Dexamethasone occurred on 10/30/24 (twice), 11/4/24 (twice) and one dose in the morning on 11/5/24. Unit Manager #2 said she could not account for the sixth dose. Unit Manager #2 said there was no evidence the the Resident received his/her Dexamethasone on 10/28/24. Unit Manager #2 said the medication order should not have been transcribed as as needed and should have been scheduled so that doses would not be missed. Unit Manager #2 said all medications should be documented in the MAR at the time of administration. During an interview on 11/6/24 at 10:50 A.M., the Director of Nurses (DON) said the Dexamethasone order for Resident #33 should have been entered differently and that record review indicated he/she missed some doses. The DON said the nurses should sign off the medication in the MAR at the time of the administration. 49428 2. Resident #18 was admitted to the facility in September 2022 with diagnoses including transient ischemic attack (brief blockage of blood flow to the brain), cerebral infarction (stroke), and chronic atrial fibrillation (afib, a condition characterized by an irregular and often very rapid heart rhythm which can lead to blood clots in the heart and increase the risk of stroke, heart failure and other heart-related complications). Review of the MDS assessment, dated 8/8/24, indicated Resident #18 had a BIMS score of 13 out of 15, indicating the Resident was cognitively intact. Review of Resident #18's current Physician's Orders indicated but was not limited to the following: -Propranolol tablet, 10 mg, give one tablet by mouth one time a day. Hold if systolic blood pressure is less than 100 (8/15/24). Review of Resident #18's September 2024 MAR indicated but was not limited to the following: 9/5/24: systolic blood pressure = 99, Propranolol administered; 9/6/24: systolic blood pressure = 94, Propranolol administered; 9/23/24: systolic blood pressure = 98, Propranolol administered; 9/24/24: systolic blood pressure = 98, Propranolol administered; 9/29/24: systolic blood pressure = 99, Propranolol administered. During an interview on 11/6/24 at 9:07 A.M., Nurse #8 reviewed Resident #18's Propranolol order. Nurse #8 said the Resident's blood pressure should be taken prior to administering the Propranolol. Nurse #8 said Propranolol should not be given if Resident #18's systolic blood pressure is less than 100. Nurse #8 and the surveyor reviewed the Resident's September 2024 MAR. Nurse #8 said the MAR indicated Resident #18 received Propranolol on 9/5/24, 9/6/24, 9/23/24, 9/24/24, and 9/29/24 when the Resident's systolic blood pressure was less than 100. Nurse #8 said the Propranolol should not have been administered on these dates per physician's order. During an interview on 11/6/24 at 9:09 A.M., Unit Manager (UM) #2 reviewed Resident #18's September 2024 MAR and said the Resident should not have received Propranolol on the days his/her systolic blood pressure was less than 100. UM #2 reviewed the Resident's nursing notes from September 2024 but did not find documentation that the physician ordered the Propranolol to be administered outside of the parameters noted in the physician's order. During an interview on 11/6/24 at 1:50 P.M., the DON said nursing is to follow physician's orders, if Resident #18's systolic blood pressure was below 100, then the Propranolol should not have been administered.

Based on observation, interview, record review, and policy review, the facility failed to provide care and treatment consistent with professional standards of practice to prevent the development or worsening of a pressure injury for one Resident (#4), out of a total sample of 26 residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure wound, assess the Resident's risk and skin per their policy, and implement interventions recommended by the wound physician timely once the area had developed, resulting in a facility acquired unstageable full thickness deep tissue injury (DTI: localized area of persistent non-blanchable discoloration resulting from intense and/or prolonged pressure and shear forces at the bone/muscle) to the left lateral heel of Resident #4 that had worsened within a week of development. Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as revised April 2018, indicated but was not limited to the following: - this procedure provides guidelines for the structured assessment and identification of resident risk of developing a pressure ulcer/injury - the purpose of a structured risk assessment is to identify all risk factors and then determine which can be modified and which cannot or which can be immediately addressed and which cannot - the risk assessment should be conducted as soon as possible after admission and repeated weekly for the first four weeks - a comprehensive skin evaluation/assessment is conducted with every risk assessment - if a resident refuses the treatment the reason for refusal, resident response and physician notification of refusal must be documented Resident #4 was admitted to the facility in July 2023 with diagnoses including: status post-surgical amputation of the right lower extremity, end stage renal disease (ESRD), diabetes mellitus (DM), and peripheral vascular disease (PVD). Review of the medical record indicated Resident #4 has a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. The Resident's healthcare proxy is not activated; he/she is their own decision maker. During an interview on 8/10/23 at 2:50 P.M., Unit Manager (UM) #1 said the Resident is his/her own person and makes their own decision, and their healthcare proxy (HCP) was not activated. She said the Assistant Director of Nurses (ADON) was also the wound nurse and could provide any information on the Resident's wound. Review of the Nursing Evaluation, dated 7/10/23, indicated under Section C that Resident #4 did not have any pressure injuries. Review of the Minimum Data Set (MDS) assessment, dated 7/16/23, indicated the Resident was at risk for developing a pressure ulcer/injury and did not currently have a pressure ulcer/injury. Review of the medical record indicated the following: - Norton Scale for predicting risk of pressure ulcer was completed on 7/25/23 and indicated the Resident was high risk with a score of 8 - Weekly skin evaluation, completed 7/26/23, indicated the Resident had a right below the knee amputation surgical site and a fistula on his/her left upper arm The record failed to indicate weekly risk assessments or skin evaluations had been completed per the facility policy. During an interview on 8/10/23 at 3:22 P.M., Regional Nurse #1 said the expectation is for skin evaluations to be completed in the medical record weekly and with any new identified skin concern. Review of the progress notes for Resident #4 indicated on 8/3/23 a pressure wound was discovered on the Resident's left lateral heel and the Resident was assessed by the wound physician. Review of the wound physician's Wound Evaluations for Resident #4, indicated but were not limited to the following: 8/3/23: Unstageable DTI to the left lateral heel, full thickness resulting from pressure - wound measurements: 2 centimeters (cm) long (L) by (x) 3.1 cm wide (W) x not measurable depth (D) - duration of wound was estimated at greater than 1 day - recommendations: off-load wound; Prevalon boot (a cushioned boot to minimize pressure, friction and shear from the feet, heels and ankles); reposition per facility protocol 8/10/23: Unstageable DTI to the left lateral heel, full thickness resulting from pressure - wound measurements: 2.4 cm L x 3.6 cm W x not measurable D (an increase in size from the previous week) - wound progress: exacerbated due to patient non-compliance with wound care - recommendations: off-load wound; Prevalon boot (a cushioned boot to minimize pressure, friction and shear from the feet, heels and ankles); reposition per facility protocol Review of the progress notes and behavior monitoring for Resident #4 from 8/3/23 through 8/10/23 failed to indicate the Resident was non-compliant with wound care treatments or interventions. During an interview on 8/11/23 at 8:04 A.M., Unit Manager #1 said Resident #4 is dependent for care and repositioning and rubs his/her left foot against the mattress resulting in the removal or disturbance of his/her dressing to the left heel wound. She said to her knowledge he/she has never refused wound care, repositioning or any type of skin assessments. Review of the Attending Physician's Note from 8/3/23 indicated but was not limited to the following: - heel wound - wound care, off-load The surveyor observed the following: - 8/9/23 at 9:05 A.M., Resident in bed on a regular mattress with no off-loading boot, pillow or device under the Resident's left foot to off-load or alleviate pressure - 8/9/23 at 3:15 P.M., Resident in bed with no off-loading boot, pillow, or device under the Resident's left foot to off-load or alleviate pressure - 8/10/23 at 4:43 P.M., Resident in bed with no off-loading boot, pillow, or device under the Resident's left foot to off-load or alleviate pressure - 8/11/23 at 8:14 A.M., Resident in bed with no off-loading boot, pillow, or device under the Resident's left foot to off-load or alleviate pressure - 8/11/23 at 9:24 A.M., Resident in bed with no off-loading boot, pillow, or device under the Resident's left foot to off-load or alleviate pressure During an interview on 8/11/23 at 10:38 A.M., Resident #4 said he/she has a wound on his/her left heel and the staff put a dressing on it daily. He/she said the staff come in and move him/her in the bed sometimes to help him/her get more comfortable but does not think it is every two hours and feels more random. He/She said they were unaware that the left foot needed to be off the bed but someone just recently came in and put a big pillow boot on his/her foot and he/she had never had it before. Review of the [NAME] Manual of Nursing Practice - 11th Edition. (2019) indicated but was not limited to the following standards of practice for positioning: - The goal of frequent position changes is to prevent contractures, stimulate circulation, and prevent pressure sores - The recommendation is to change body position at least every 2 hours and, preferably, more frequently in patients who have no spontaneous movement Review of the documentation for Resident #4's repositioning for July 2023 through August 11, 2023, indicated but was not limited to the following: - 7/12/23, Wednesday: at 4:00 P.M., 6:00 P.M., and 8:00 P.M., No (N) - the Resident was not repositioned - 7/13/23, Thursday: at 12:00 A.M., 2:00 A.M., 4:00 A.M., and 6:00 A.M., - the documentation was blank - 7/14/23, Friday: at 8:00 A.M., 10:00 A.M., 12:00 P.M., and 2:00 P.M., - the documentation was blank - 7/17/23, Monday: at 8:00 A.M., 10:00 A.M., 12:00 P.M., and 2:00 P.M., - the documentation was blank - 7/19/23, Wednesday: at 8:00 A.M., and 2:00 P.M., not applicable (NA) - 7/23/23, Sunday: at 8:00 A.M., 10:00 A.M., 12:00 P.M., and 2:00 P.M., - the documentation was blank - 7/28/23, Friday: at 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M., - the documentation was blank - 8/5/23, Saturday at 2:00 A.M., 4:00 A.M., and 6:00 A.M., No (N) - the Resident was not repositioned - 8/9/23, Wednesday at 12:00 A.M., and 2:00 A.M., No (N) - the Resident was not repositioned Review of the Resident record indicated the Resident leaves the facility every Tuesday, Thursday, and Saturday for a 10:15 A.M., dialysis session and does not return to the facility until between 3:00 P.M., and 4:00 P.M. on those days. During an interview on 8/11/23 at 10:51 A.M., Certified Nurse Assistant (CNA) #5 said she helps reposition Resident #4 in bed sometimes and does not recall the Resident having any devices to off-load his/her heel. She said all residents are supposed to be repositioned every two hours if they cannot do it themselves. During an interview on 8/11/23 at 11:00 A.M., CNA #4 said she was assigned to Resident #4 on this day. She said he/she requires assistance with all care and positioning. She said he/she has a dressing on his/her left foot that is done by the nurses but she does not know about any pillow or device to be placed on or under the Resident's left foot to keep it up off the bed and she did not do that for the Resident today. She said all residents should be repositioned every two hours and on review of the CNA documentation could not explain why there were gaps in Resident #4's repositioning. During an interview on 8/11/23 at 12:01 P.M., the ADON said the expectation is that [NAME] pressure risk assessments are completed on admission and then weekly for four weeks and weekly skin evaluations are signed off on the treatment administration record (TAR) after the evaluation is completed and documented. She reviewed the medical record and said, that although the TAR was signed, there was only one [NAME] pressure risk assessment completed on 7/25/23, indicating the Resident was high risk for pressure ulcer development and only one weekly skin evaluation completed on 7/26/23 and the process was not followed. She said typically when a resident is considered high risk for pressure ulcer development the facility implements interventions such as every two hour repositioning, off-loading of the heels/feet with elevation and placement of a pillow, skin prep treatment to the heels and continues to complete [NAME] pressure risk assessments. She reviewed Resident #4's medical record and said she could not find any documentation that indicated any of these or any other preventative interventions were in place to prevent the pressure ulcer that developed to Resident #4's left lateral heel. She reviewed the repositioning documentation for Resident #4 and said there were times when the repositioning was not completed or documented as it should have been and it appeared the Resident was not repositioned according to the standard. She said on 8/3/23 she was doing wound rounds when she was alerted that Resident #4 had a new area on his/her left heel and the Resident was evaluated by the wound physician that day and again on 8/10/23. She said the wound had worsened on 8/10/23 and the physician wrote it was related to the Resident being non-compliant but she could not explain why the physician documented that and said there was no documentation of the Resident being non-compliant to wound care, treatments or repositioning and she was not aware of any issues. She said the recommendation on 8/3/23 for the use of a Prevalon boot to off-load the heel was not implemented or addressed until 8/10/23 and she placed the Prevalon boot on the Resident this morning for the first time. She said the recommendations for off-loading of the left heel and use of the Prevalon boot from 8/3/23 were not implemented as they should have been and she could not find any documentation as to why the Resident did not have these interventions implemented. During an interview on 8/15/23 at 9:08 A.M., Wound Physician #1 said he evaluated Resident #4 initially on 8/3/23 and assessed the area on the left lateral heel to be a full-thickness unstageable DTI due to pressure. He said on 8/3/23 he placed recommendations for a dressing, off-loading of the wound, use of a Prevalon boot, repositioning, and some labs. He said when he re-evaluated the Resident on 8/10/23 the wound had been exacerbated (worsened) and he assumed that since the Resident did not have the off-loading or Prevalon boot in place at the time of the re-evaluation that the Resident was non-compliant. He said he was not aware the facility had not yet implemented his recommendations from the 8/3/23 visit. He said prevention of pressure ulcer development is best practice to help avoid an area that may be difficult to heal. He said the Resident had a lot of risk factors for pressure development and should have had preventative measures in place to help avoid the development of the left lateral heel ulcer that developed within the facility. During an interview on 8/15/23 at 10:21 A.M., the Director of Nurses said Resident #4 was high risk for pressure ulcer development and the expectation is that he/she should have had their risk assessments, skin evaluations and pressure prevention interventions in place and the medical record does not indicate that those things occurred, and the process was not followed as it should have been. During an interview on 8/15/23 at 2:01 P.M., Attending Physician #1 said Resident #4 was fragile and had a poor medical trajectory. He said he was aware the Resident had a pressure ulcer that had developed in the facility on his/her left heel, the etiology (cause) of the wound was pressure and the Resident was being managed for the wound by the facility wound physician. He said he wrote a note on the Resident on 8/11/23 that indicated: despite appropriate treatment the left lower extremity wound was medically unavoidable. He said the facility made him aware on 8/11/23 that there were no preventative measures in place to prevent the pressure ulcer from developing and the facility had not implemented the wound physician's recommendations from 8/3/23 until 8/11/23. He said he did document for the facility to off-load the wound in his 8/3/23 note and his expectation is when he requests preventative measures the facility implements them in hopes of preventing further issues and the facility made him aware on 8/11/23 that that did not occur.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure staff followed Resident #1's plan of care related to transfers, when Resident #1, who required the assistance of two staff members with all transfers, was transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #1, without another staff member, resulting in Resident #1 sustaining a laceration to his/her left lower extremity, which required seventeen sutures to close. Findings include: The Facility's Policy titled, Activities of Daily Living (ADL's) indicated appropriate care and services will be provided for residents who are unable to carry out ADL's independently in accordance with the plan of care, including appropriate support and assistance with mobility, transfer and ambulation. The Policy indicated the residents' ability to perform ADL's will be measured using clinical tools including the MDS, and defined extensive assist as: resident performed part of the activity and staff provided weight-bearing support. The Policy titled, Comprehensive Person-Centered Care Plans, dated as revised in (MONTH) (YEAR), indicated that the Interdisciplinary Team develops a comprehensive, person-centered care plan for each resident to meet the resident's physical, psychosocial and functional needs. The Policy indicated care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and aid in preventing or reducing decline in the resident's functional status. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Sheet (MDS) Assessment, dated 2/12/19, indicated Resident #1 required extensive assist of two staff members for transfers. Resident #1's Mobility Impairment Care Plan, dated initiated 2/26/19, indicated Resident #1 had a physical functioning deficit related to mobility impairment due to weakness and required assist of two staff members for transfers. Resident #1's Care Kardex Report, undated, indicated Resident #1 required extensive assist of two staff members with transfers. A Resident Event Report, dated 3/17/19 at 9:30 A.M., indicated Resident #1 sustained a laceration which was bleeding profusely to his/her left lower leg while being transferred by CNA #1. The Report indicated a makeshift tourniquet and pressure was applied to the injury and that 911 (Emergency Medical Services) was called. A physician's orders [REDACTED].#1 to the hospital emergency department. The Health Care Facility Reporting System (HCFRS) Report, dated 3/22/19, indicated that on 3/17/19 at 9:30 A.M., Resident #1 was being transferred from bed to wheelchair by CNA #1 when his/her left leg was caught on the bracket that holds the wheelchair pedals. The Report indicated Resident #1 sustained a five inch long by one half inch wide laceration to his/her left lower leg and was transferred to the hospital where he/she required seventeen sutures to close the laceration. CNA #1's written witness statement, dated 3/17/19, indicated CNA #1 transferred Resident #1 from bed to the wheelchair, noticed blood and that Resident #1 was cut by the wheelchair and notified the nurse. A Nurse Progress Note, dated 3/17/19, indicated that at approximately 9:30 A.M., Resident #1 was being transferred from bed to chair when his/her left leg came in contact with the leg rest bracket and a large five inches long by one half inch wide laceration was noted with profuse bleeding. The Note indicated a makeshift tourniquet was applied above the laceration, pressure was applied, 911 was called and Resident #1 was transferred to the hospital. The Note indicated that Resident #1 returned to the Facility from the hospital with seventeen sutures to his/her left lower extremity. A Hospital Emergency Department Report, dated 3/17/19, indicated Resident #1 was seen for wound care. Discharge instructions included: daily dressing changes with [MEDICATION NAME] (antibiotic ointment) and dry sterile gauze, to return for increased redness, swelling, fevers, and to have sutures out in 10 - 14 days. The Surveyor interviewed CNA #1 at 11:32 A.M. on 4/9/19. CNA #1 said Resident #1 was a two person assist with transfers and said she transferred Resident #1 without an assist. CNA #1 said that after she transferred Resident #1 from the bed to the wheelchair, she noticed that Resident #1 was bleeding from a cut on his/her left leg and that blood was dripping on the floor. CNA #1 said she notified the nurse. The Surveyor interviewed Nurse #1 at 12:20 P.M. on 4/9/19. Nurse #1 said CNA #1 notified her that Resident #1 was bleeding badly from a cut to his/her leg. Nurse #1 said a tourniquet and pressure was applied to the cut because it was bleeding so much. Nurse #1 said she asked CNA #1 if she transferred Resident #1 without assistance and said that CNA #1 said she transferred Resident #1 without an assist. Nurse #1 said that Resident #1 required the assistance of two staff members with transfers and said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. on 4/9/19. The DON said Resident #1's plan of care for transfers indicates that he/she is an extensive assist of two staff members, said CNA #1 transferred Resident #1 from the bed to the wheelchair without assist of another staff member and said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Nursing Supervisor at 3:06 P.M. on 4/17/19. The Nursing Supervisor said Resident #1's plan of care for transfers indicated he/she required assist of two staff members. The Nursing Supervisor said CNA #1 transferred Resident #1 without assist.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required extensive assistance of two staff members with transfers, the Facility failed to ensure staff maintained his/her safety to prevent any injury or accident during a transfer and failed to ensure Resident #1 was provided with adequate assistance during a transfer, when Resident #1 was transferred by Certified Nurse Aide (CNA) #1, unassisted by another staff member, and sustained a laceration to his/her left lower extremity that required seventeen sutures to close. Findings include: The Facility's Policy titled, Activities of Daily Living (ADL's) indicated appropriate care and services will be provided for residents who are unable to carry out ADL's independently in accordance with the plan of care, including appropriate support and assistance with mobility, transfer and ambulation. The Policy indicated the residents' ability to perform ADL's will be measured using clinical tools including the Minimum Data Set (MDS), and defined extensive assist as: resident performed part of the activity and staff provided weight-bearing support. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Sheet (MDS) Assessment, dated 2/12/19, indicated Resident #1 required extensive assist of two staff members for transfers. Resident #1's Mobility Impairment Care Plan, dated initiated 2/26/19, indicated Resident #1 had a physical functioning deficit related to mobility impairment due to weakness and required assist of two staff members for transfers. Resident #1's Care Kardex Report, undated, indicated Resident #1 required extensive assist of two staff members with transfers. A Resident Event Report, dated 3/17/19 at 9:30 A.M., indicated Resident #1 sustained a laceration, which was bleeding profusely, to his/her left lower leg while being transferred by CNA #1. The Report indicated a makeshift tourniquet and pressure was applied to the injury and that 911 (Emergency Medical Services) was called. A physician's orders [REDACTED].#1 to the hospital emergency department. The Health Care Facility Reporting System (HCFRS) Report, dated 3/22/19, indicated that on 3/17/19 at 9:30 A.M., Resident #1 was being transferred from bed to wheelchair by CNA #1 when his/her left leg was caught on the bracket that holds the wheelchair pedals. The Report indicated Resident #1 sustained a five inch long by one half inch wide laceration to his/her left lower leg and was transferred to the hospital where he/she required seventeen sutures to close the laceration. CNA #1's written witness statement, dated 3/17/19, indicated CNA #1 transferred Resident #1 from bed to the wheelchair, noticed blood and that Resident #1 was cut by the wheelchair and notified the nurse. A Nurse Progress Note, dated 3/17/19, indicated that at approximately 9:30 A.M., Resident #1 was being transferred from bed to chair when his/her left leg came in contact with the leg rest bracket and a large five inches long by one half inch wide laceration was noted with profuse bleeding. The Note indicated a makeshift tourniquet was applied above the laceration, pressure was applied, 911 was called and Resident #1 was transferred to the hospital. The Note indicated that Resident #1 returned to the Facility from the hospital with seventeen sutures to his/her left lower extremity. A Hospital Emergency Department Report, dated 3/17/19, indicated Resident #1 was seen for wound care. Discharge instructions included: daily dressing changes with [MEDICATION NAME] (antibiotic ointment) and dry sterile gauze, to return for increased redness, swelling, fevers, and to have sutures out in 10 - 14 days. The Surveyor interviewed CNA #1 at 11:32 A.M. on 4/9/19. CNA #1 said Resident #1 was a two person assist with transfers and said she transferred Resident #1 without an assist. CNA #1 said that after she transferred Resident #1 from the bed to the wheelchair, she noticed that Resident #1 was bleeding from a cut on his/her left leg and that blood was dripping on the floor. CNA #1 said she notified the nurse. The Surveyor interviewed Nurse #1 at 12:20 P.M. on 4/9/19. Nurse #1 said CNA #1 notified her that Resident #1 was bleeding badly from a cut to his/her leg. Nurse #1 said a tourniquet and pressure was applied to the cut because it was bleeding so much. Nurse #1 said she asked CNA #1 if she transferred Resident #1 without assistance and said that CNA #1 said she transferred Resident #1 without an assist. Nurse #1 said that Resident #1 required the assistance of two staff members with transfers and said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. on 4/9/19. The DON said Resident #1's plan of care for transfers indicates that he/she is an extensive assist of two staff members, said CNA #1 transferred Resident #1 from the bed to the wheelchair without assist of another staff member and said CNA #1 did not follow Resident #1's plan of care for transfers. The Surveyor interviewed the Nursing Supervisor at 3:06 P.M. on 4/17/19. The Nursing Supervisor said Resident #1's plan of care for transfers indicated he/she required assist of two staff members. The Nursing Supervisor said CNA #1 transferred Resident #1 without assist.

Based on record review, observation and staff interview, the facility staff failed to ensure that Residents maintain acceptable parameters of nutrition, including weight and hydration status, for 1 sampled Residents (#83), from a total sample of 25 Residents. Findings include: 1. For Resident #83, the facility failed to prevent a continued, significant weight loss of 55 pounds within 180 days and failed to thoroughly assess and promote the Resident's hydration status after a hospitalization . Resident #83 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the medical record indicated that on 4/23/18 and 7/23/18 the Dietitian documented in the quarterly nutrition assessments that the Resident weighed approximately 255 pounds and was admitted to the facility at 217 pounds. The Dietitian documented that the Resident would not always allow the staff to weigh him/her. The Dietitian also documented that although she recommended weight loss, the Resident was not in agreement with that recommendation. Review of the care plan dated 7/23/18 indicated that the Resident was at Nutrition risk due to dementia and psychiatric issues. The approaches included: -diet order regular food mechanical soft -monitor for dehydration -monitor for signs and symptoms (S/S) of aspiration -monitor labs -screen evaluation for rehab services On 9/17/18 the Resident returned from a hospitalization (8/30/18 - 9/17/18). Nursing staff obtained a readmission weight of 226.9 pounds and documented it in the Weight Summary. On 10/2/18 (15 days later) the Dietitian documented in a Weight Change note, (located in the progress note section of the medical record), that the Resident weighed 226.9 pounds and had a significant weight loss of 10% in 180 days. The Dietitian further documented return from MLOA (Medical Leave of Absence), weight loss is not a concern, weight and BMI (Body Mass Index) elevated. The care plan was not changed nor were that any new interventions to address the Resident's significant weight loss. Review of the most recent quarterly Minimum Data Set, with a reference date of 10/23/18, indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 11 of 15 reflecting moderately impaired cognition, no documented behaviors, required supervision and assist for eating, weighed 209 pounds and had a significant weight loss that was not prescribed by a physician. On 10/24/18, the Dietitian documented a quarterly nutrition assessment indicating that the Resident weighed 209 pounds, had unintended weight loss and difficulty swallowing pills. The Dietitian documented in the narrative that the Resident may have experienced significant weight loss in the past 30 days. The plan was to get a speech therapy evaluation and obtain weekly weights. The care plan was revised that indicated to Monitor for S/S dehydration. There were no new interventions to address the additional significant weight loss of 17.9 pounds (7.8%) within 30 days. On 11/14/18, the Dietitian documented in a Weight Change note that the Resident weighed 204 pounds, and had a significant weight change and the weight loss had been addressed, referring to the 10/24/18 quarterly nutrition assessment note. The Dietitian failed to identify that the Resident had lost an additional 5 pounds since 10/24/18, and failed to address this change or provide interventions to stop the continued weight loss. On 12/10/18, the Dietitian documented in a Nutrition progress note that the Resident weighed 198 pounds (on 12/3/18) and had lost a total of 55.2 pounds in 180 days related to behaviors and texture modification. The Dietitian further documented that the Resident was being reviewed by the psychiatry consulting service, but there were no documented changes in meal intake. The only recommendation made was to add a supplement of 237 ml of Glucerna 1.2 at 2 P.M The supplement added approximately 284 calories per serving. Review of the nursing progress notes, dated 12/13/18, indicated that the Resident was alert but lethargic, sleepy with decreased activity. The nurse documented that the Resident had not been eating for days and had a very poor drinking pattern. The nurse contacted the physician and reported the Resident's physical and medical change. The physician identified he would be coming into the facility the next day. On 12/15/18, the nurse documented that the Resident was transferred to the hospital for evaluation because the Resident was found less responsive, lethargic and haggard. On 12/16/18, the nurse contacted the hospital and was notified that the Resident was admitted with the [DIAGNOSES REDACTED]. On 12/19/18, the Resident was readmitted to the facility. The Resident had been treated for [REDACTED]. On 12/21/18, the Resident was evaluated by the Speech Therapist and indicated the Resident was at base line and did not require any further skilled services from Speech Therapy. Review of the Weight Summary for Resident #83, indicated on 12/25/18 the Resident weighed 192.6 pounds, an additional 6 pound weight loss since 12/3/18. On 12/26/18, the Dietitian's nutrition assessment/progress note indicated the same information previously identified, repeating that the Resident that a significant decline in weight and received a supplement once a day. The Dietitian inaccurately documented that the Resident was in for a psychiatric hospital admission instead of receiving treatment for [REDACTED]. The Dietitian failed to implement new plans to address the recent hospital [DIAGNOSES REDACTED]. Review of the Weight Summary for Resident #83 indicated that on 1/4/19 the Resident weighed 191.4 pounds. On 1/22/19, the Dietitian documented and confirmed in a Weight Change note, that the Resident's weight loss had been addressed, referring to the 12/26/18 nutrition progress note which did not identify any new interventions to prevent further weight loss. Review of the Weight Summary for Resident #83, indicated that on 1/23/19 the Resident weighed 190.0 pounds, an additional 1 pound weight loss since 1/4/19. Review of the Dietitian's Annual Nutrition Assessment, dated 1/28/19 for Resident #83, summarizing the past year for the Resident identifying significant weight loss with episodic non-compliance with taking his/her medication. The Dietitian indicated the Resident's meal intake was better and his/her the rate of weight loss was slowing. The nutritional plan was to continue with the plan that the Resident was at nutrition risk related to behaviors with goal to stabilize weight within acceptable range and prevent aspiration. The Dietitian did not identify what that weight range should be. On 2/7/19 at 8:23 A.M., the Surveyor observed that the Resident did not eat any of his/her breakfast. The Resident said they make me eat things I don't like, like eggs. Review of the documentation of the Resident's Meal Percentage intake for 2/7/19 (breakfast meal) indicated the Resident consumed 25-50% and drank 240 ml of fluids, which was inaccurate to the Surveyor's observation which indicated the Resident did not eat his/her breakfast or consume any fluids. On 2/8/19 at 10:45 A.M., the Director of Nurses was interviewed and the Surveyor asked for clarification on how to interpret the meal percentage documentation. It was identified that CNA #2 was incorrectly documenting the amount that the Resident consumed at meals and over estimating what the Resident consumed for fluids. On 2/8/19 at 11:30 A.M., the Facility's Dietitian was interviewed via telephone. The Dietitian said that she was aware of the Resident's weight lost but felt it was due to the Resident's behavior. The Surveyor asked if she was aware of the Resident's most recent hospitalization when the Resident was treated for [REDACTED]. The Dietician said yes she evaluated the Resident after he/she returned. The surveyor identified that the nutrition assessment, dated 12/26/18 (7 days after readmission), failed to indicate any new changes to the care plan at that time. The Dietitian said that she had time constraints and is a little behind in his/her documentation. The Surveyor identified to the Dietitian that the meal percentage documentation, including fluid intake was not accurately documented by the CNA's consistently. The Dietitian said yes she was aware but had not shared that information with Administration staff. On 2/8/19 at 1:44 PM, the Administrator and the Director of Nurses were interviewed and said that they had an At Risk meeting weekly to discuss weight loss, change in cognition, falls, skin, behaviors and restraints. They both said that they were aware of Resident #83's weight loss. They said that on 12/10/18, a supplement was started, however they could not provide the Surveyor with any additional interventions that were provided to the Resident to help prevent further weight loss.

Based on records reviewed, observations and interviews, for 5 of 28 sampled residents (Resident #1, Resident #2, Resident #4, Resident #16, Resident #22), the facility failed: - to ensure that reports of alleged abuse and/or neglect were reported to the Department of Public Health (DPH) within two hours as required; - to conduct thorough investigations of alleged incidents of abuse and neglect, including interviewing any persons who might have knowledge of the alleged incident, and obtaining written statements; - to protect residents from accused staff persons following reports of alleged abuse; - to ensure employees, including those from nurse staffing agencies, received training on the obligation to report alleged violations, examples of reportable incidents to assist staff in detection of such incidents, appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, and caregiver stress; and, - to conduct reference checks with the current and/or past employer, appropriate licensing board or registry check, and criminal background checks for all applicants for employment prior to the date of hire. Findings include: 1. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that an initial report of allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin, and misappropriation of resident property must be made within two hours to the State Survey Agency (DPH) and law enforcement. A. The Surveyor interviewed Resident #1 at multiple times on 10/08/17. Resident #1 said staff was rude and mean, and that he/she did not feel safe in facility and was scared. Resident #1 said Nurse #2 told him/her to call 911 himself/herself if he/she did not feel well and wanted to go to the hospital; that Nurse #2 controlled the unit in a vindictive manner; and, that Nurse #2 openly yelled at residents, family and staff. Resident #1 said she had heard a CNA (Certified Nurse Assistant; identified by the Facility as CNA #1) slap Resident #2. Resident #1 said he/she heard Resident #2 say you slapped me, or words to that effect, and heard CNA #1 responded you slapped me first, or words to that effect. Resident #1 said he/she knew the CNA's name and that the CNA was currently employed at the Facility. Resident #1 said he/she told the Family Member that CNA #1 slapped Resident #2, and said he/she reported the incident to other people. Resident #1 said he/she was afraid to report the incident to staff because he/she and his/her Family Member had reported concerns in the past without resolution. The Surveyor interviewed the Administrator at 12:00 P.M. on 10/08/17. The Surveyor asked the Administrator to speak with Resident #1 as he/she reported being afraid of the staff and had concerns about the care he/she received. At 12:15 P.M. on 10/08/17, the Administrator said Resident #1 reported that he/she heard Resident #2 being slapped approximately two months prior. The Administrator said Resident #1 said he/she heard the slap, but had not witnessed it and had not reported it to anyone. The Surveyor told the Administrator that Resident #1 also reported a number of allegations that included neglect, intimidation and a fear of staff. The Administrator said Resident #1 had mental illness and had not reported any other allegations. The Facility's internal investigation indicated that the alleged incidents were not reported to the DPH until 10/11/17, 3 days after being reported to the Administrator by the Surveyor. There was no documentation at the time of survey that Resident #1's allegations were reported to the DPH within 2 hours as required. B. The Surveyor interviewed Resident #16 at 9:24 A.M. on 10/12/17. Resident #16 said that on 10/10/17, he/she spoke with Social Worker #1 regarding CNA #2. Resident #16 said he/she told Social Worker #1 that on 10/09/17, CNA #2 did not provide him/her with adequate care, particularly regarding personal hygiene needs. Resident #16 said that CNA #2 often provided inadequate care, citing personal illness or injury as a reason why she couldn't provide the care. The Surveyor interviewed Social Worker #1 at multiple times throughout the dates of survey. Social Worker #1 said she spoke with Resident #16 on 10/10/17. Social Worker #1 said Resident #16 told her that CNA #2 would not provide care to him/her, and would not allow other staff to provide care to him/her either. Social Worker #1 said Resident #16 told her that he/she was really concerned about not getting care as he/she had a coccyx (tailbone area) wound. Social Worker #1 said she did not notify the Administrator of Resident #16's allegation until the following day (10/11/17). Social Worker #1 said she was unaware of the 2 hour reporting requirement, and knew she should not have waited to notify the Administrator. On 10/13/17, the Surveyor observed a reddened and excoriated stage I (an observable pressure-related alteration of intact skin) on Resident #16's right buttock, and a stage II (Partial thickness skin loss) of the left buttock. The Surveyor interviewed the Director of Nurses (DON) at multiple times on 10/12/17. The DON said she was unaware of the two areas of altered skin integrity on Resident #16's buttocks. The Facility's internal investigation indicated that Resident #16's allegation was not reported to the DPH until 10/13/17, 3 days after being reported to Social Worker #1 and 2 days after being reported to the Administrator. There was no documentation at the time of survey that Resident #16's allegations were reported to the DPH within 2 hours as required. C. The Facility's internal investigation indicated that on 06/01/17, Resident #22 reported to the Director of Activities that Nurse #4 pulled down her own pants to show Resident #22 a scar, and Resident #22 was uncomfortable with what he/she perceived as inappropriate behavior by Nurse #4. The investigation indicated that the Director of Activities notified the Director of Nurses (DON) on 06/01/17 and that the Interim DON was notified of the alleged incident on 06/07/17, but the incident was not reported until 06/09/17, 8 days after the alleged incident. Resident #22 could not be interviewed as he/she no longer resided at the Facility at the time of survey. The Interim DON could not be interviewed as she no longer worked at the Facility at the time of survey. There was no documentation at the time of survey that Resident #22's allegation was reported to the DPH within 2 hours as required. 2. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that all investigations shall include interviews of employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident. The Policy indicated that written statements from involved parties may be requested. The Administrator said he was primarily responsible for conducting investigations into allegations. The Administrator said he asked staff for written statements, but did not always get them. A. The Facility's internal investigation into the allegations of abuse and mistreatment of [REDACTED].#2 included a written statement from Nurse #2, but did not include written statements from or interviews with, employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident. There was no documentation at the time of survey that the Facility interviewed or obtained written statements from any other persons who might have knowledge of the alleged incident. B. The Facility's internal investigation into the allegation that CNA #1 slapped Resident #2 did not include written statements from or interviews with, employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident, including the accused CNA (CNA #1). There was no documentation at the time of survey that the Facility interviewed or obtained written statements from any other persons who might have knowledge of the alleged incident. 3. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, did not include the protection of residents or staff following the report of alleged violations including abuse, neglect, and mistreatment. The Administrator said that the Facility did not necessarily have a sufficient number of staff to shuffle people around, or words to that effect, when a resident complained about a staff person. A. The Surveyor interviewed Resident #4 at 11:30 A.M. on 10/12/17. Resident #4 said that on approximately 08/31/17, CNA #5 pushed his/her wheelchair into the wall of the elevator, and then whispered into Resident #4's ear that she wanted to push Resident #4 down the stairs, and that CNA #5 could do whatever she wanted to Resident #4 and no one would ever know, or words to that effect. The Facility's internal investigation indicated that Resident #4 had a history of [REDACTED].#5, and had requested that CNA #5 not provide care to him/her. However, Resident #4's clinical record did not indicate that he/she had a history of [REDACTED]. The investigation indicated that the Facility would ensure that CNA #5 did not provide care to Resident #4, to the extent possible, and CNA #5 would ensure another care partner accompanied her when necessary. However, review of Facility schedules dated 09/27/17 through 10/19/17 indicated that CNA #5 was scheduled to work on Resident #4's unit for 15 of those 23 days. There was no documentation at the time of survey that the Facility protected either Resident #4 or CNA #5 following an allegation of abuse. B. The Facility's internal investigation into the allegation that Nurse #4 pulled down her own pants in front of Resident #22 included a written statement from Nurse #4 confirming that the incident occurred. The investigation indicated that the allegation was substantiated, and Nurse #4 no longer worked at the Facility. The Surveyor interviewed the Human Resources staff at 11:00 A.M. on 10/19/17. The Human Resource staff said Nurse #4 did not work at the Facility for a period of time, but was reinstated on 07/21/17, prior to the Resident #22's discharge from the Facility. The Facility nursing staff schedules indicated that Nurse #4 returned to work at the Facility on 07/21/17, on Resident #22's unit. The schedules indicated that as of the dates of survey, Nurse #4 continued to work at the Facility despite the Facility's action plan that she would no longer do so. Resident #22's clinical record indicated that Nurse #4 provided direct care for Resident #22 on 08/04/17, 08/05/17 and 08/17/17. There was no documentation at the time of survey that the Facility followed its own action plan of not having Nurse #4 work at the Facility, in an effort to protect Resident #22. 4. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that during orientation, new employees shall be trained on the obligation to report alleged violations, examples of reportable incidents to assist staff in detection of such incidents, appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, and caregiver stress. The Policy indicated that each employee would receive annual training on the requirements of the Facility's policies and procedures regarding alleged violations and the requirements of State and Federal law. A. Social Worker #1 said she received abuse training during orientation, but that it only included a video. Social Worker #1 said the video did not include the reporting of alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, immediately, but not later than 2 hours after the allegation is made. B. Review of Facility nurse staff schedules dated 09/27/17 through 10/12/17 indicated that of 372 scheduled licensed or registered nurse positions across all three shifts (7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M. to 7:00 A.M.), 166 of those positions were filled by nurse staffing agency personnel, for an average of 45% of licensed or registered nurse personnel. i. Review of the Facility's 11 contracted nurse staffing agencies indicated that 5 of the contracts (Agency #1, Agency #2, Agency #3, Agency #4, and Agency #11) did not stipulate whether the agency or the Facility was responsible for ensuring training on the Facility's policies and procedures regarding alleged violations and the requirements of State and Federal law. ii. Review of the contracts for Agency #7 and Agency #9 indicated that the Facility was responsible for ensuring training on the Facility's policies and procedures regarding alleged violations and the requirements of State and Federal law. iii. The Facility's Agency Documentation book indicated that of 38 licensed or registered agency nurse personnel, only 8 had documentation at the time of survey of orientation to the Facility, including abuse, neglect, and misappropriation of resident property. 5. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that all applicants for employment should have checks including: reference checks with the current and/or past employer, appropriate licensing board or registry check, and criminal background checks. The Surveyor interviewed the Regional Nurse Consultant at multiple times throughout the dates of survey. The Regional Nurse Consultant said the Facility employed a human resources consultant, who was responsible for ensuring that personnel files were complete, accurate, and up-to-date. A. Nurse Supervisor #1 was hired by the Facility as a nurse in September 2017. The Board of Registration in Nursing license verification was dated for 6 days after Nurse Supervisor #1's date of hire. There also was no documentation at the time of survey of any reference checks done prior to, at the time of, or after Nurse Supervisor #1's date of hire. B. Nurse #1 was hired by the Facility as a nurse in September 2017. There was no documentation at the time of survey of any reference checks done prior to, at the time of, or after Nurse #1's date of hire. C. Nurse #2 was hired by the Facility as a nurse in December 2006. There was no documentation at the time of survey of any reference checks done prior to, at the time of, or after Nurse #2's date of hire. D. CNA #1 was hired by the Facility as a CNA in November 2013. Review of CNA #1's personnel file indicated that she resided out-of-state. There was no documentation at the time of survey of any reference checks done prior to, at the time of, or after CNA #1's date of hire. There also was no documentation at the time of survey of an out-of-state Nurse Aide Registry (NAR) check, or of a current valid CNA certificate. E. CNA #2 was hired by the Facility as a CNA in August 2016. There was no documentation at the time of survey of any reference checks done prior to, at the time of, or after CNA #2's date of hire.

Based on record review and interviews the facility failed for 2 (#1, and #4) of 28 sampled Residents to ensure that grievances were thoroughly investigated according to facility policy, and failed to ensure efforts were promptly made to effectively resolve concerns identified for all residents. Findings include: The facility's Grievance Guideline indicated all employees are responsible for ensuring customer satisfaction. The Facility's Grievance Guidelines indicated that when concerns arise, a grievance system is in place to resolve the issues to the satisfaction of all parties involved. The response to the grievance should be addressed as soon as possible and/or within five working days of receipt of the Grievance Form. The Grievance process indicated that the Facility staff would ensure resolution of grievances and whether or not the Resident and/or the individual filing the grievance felt satisfaction in the process. The process identified the Social Worker as the designated staff responsible for regulatory compliance and was responsible for updating, tracking and maintaining a Grievance Log for 7 years (electronically). The Administration staff maintained daily oversight, tracking and management of grievances and frequently reported grievances and that Administration staff provided assistance in resolving the grievance. The Facility indicated that the grievance and resolution shall be completed timely and the investigation should include evaluating all aspects of the situation including interviewing the resident and/or person completing the form. The process indicated that an action plan would be implemented and that the individual filing the grievance would be notified of the findings in person, by telephone, in writing or by e-mail. 1. The Grievance Log was reviewed after receiving complaints from the Ombudsman, the Social Worker, Residents (#4) and the Resident Council that the Facility did not make an effort to resolve their grievances. They said that they were not apprised of the investigation, action plan and resolution to any of their complaints. The consensus was they felt the Staff's treatment to the residents was disrespectful and intimidating and Residents had experienced instances in which the Facility Staff yelled at them for using their call lights and threatened them to not report their complaints. The Residents said that the Administration disregarded their complaints and that the staff (especially agency staff) made up rules as they went along and did not allow them to report complaints. According to the policy all grievances were tracked onto a Grievance Log, the Social Worker (SW) was to track grievances by logging in the date of the incident, the Resident involved, who voiced the grievance (including Resident Council concerns), nature of concern, responsible department, action plan, resolution and follow up. Review of the tracking logs indicated that the SW had not consistently entered grievances onto the tracking logs. There were no grievances filed between 4/19/16 and 6/11/17 and 6/28/17 through 10/10/17 and from 6/11/17 through 6/26/17, 8 grievances were tracked onto the log form. Review of the grievances filed include: - On 6/11/17, the Resident complained he/she had to wait for call bell to be answered. The form indicated that the staff was counseled on timely call light monitoring. The form indicated that the grievance was resolved and they had reviewed the resolution with the Resident on 6/14/17. There was not evidence of a long term plan. - On 6/12/17, the Resident complained that a CNA (Certified Nurse Assistant) was rude and asked that the Resident do something they felt he/she could do. The staff was counseled on customer service and resident perception. The Facility signed that the grievance was resolved and they had reviewed the resolution with the Resident on 6/16/17. The grievance indicated it was Resident perception and did not indicate they provided a plan to ensure the Resident was protected and that there was a long term plan to prevent the incident from reoccurring. - On 6/14/17, the Resident (#4) complained that the CNA was rude and failed to assist when asked for help. The staff was counseled on customer service and resident perceptions. The Facility signed that the grievance was resolved and they had reviewed the resolution with the Resident on 6/16/17. On 10/12/17 at 10:30 A.M., Resident #4 was interviewed and said that filing grievances were pointless. Resident #4 said that the staff back each other up when asked about a situation and then the staff become total terrors (towards the Resident). The Resident said that the Facility does not ensure that he/she is protected from staff and that things do not change. - On 6/15/17, the Resident complained that the 11:00 P.M. to 7:00 A.M. shift failed to complete all the things he/she wants before they left him/her (access to television remote). Resolution was a care plan for behaviors, psych consult and 2 staff to provide care due to accusatory behaviors. The Facility signed that the grievance was resolved and they had reviewed the resolution with the Resident on 6/16/21. The grievance did not address the grievance and based the plan as a behavior of the Resident and there was no long term plan. - On 6/19/17, One of the three Units staff reported they did not receive breakfast foods as requested. Money was to be left to purchase food for items if needed. The SW signed the grievance as resolved on 6/23/17. The grievance did not include any additional course of action and there was no indication who was notified of the resolution. During the survey, the issue was brought to the attention of the Administration staff on 10/12/17 and the Administrator said he did not know about the situation. - On 6/20/17, the Resident reported a broken hearing aid. The grievance was incomplete and contained no evidence that the broken hearing aid was repaired. - On 6/25/17, the Resident's Family voiced concerns that another resident was asking them to assist in care. The action plan included a room change for the Resident (who was not asking for help from family), that it was reviewed with the complainant and resolved on 6/26/17. - On 6/26/17, the Resident's Family complained that a new shirt was missing. The Facility determined that a CNA threw it out because it was full of feces. The Facility educated the CNA and offered replace the shirt. Although, the grievance was signed as resolved on 6/27/17 there was no documentation indicating the shirt was replaced. Additionally, although the policy was to track all grievances onto the log forms, 12 grievances were not entered on the grievance log which were reviewed. Review of the 12 indicated that 10 of the 12 grievances failed to ensure resolution according to Facility procedure. - 5/9/17, the Family complained that the resident had a bruise from shirt being removed, hand contracture caused nail to dig into skin. The action plan indicated that the Resident was to wear palm guards and to have family buy shirts that were easier to remove and that they had contacted the Family who were very thankful and agreeable to resolution on 5/11/17. There was no additional information ensuring that staff were provided education on care (including nail care) or had a long term plan for the resident. - 5/9/17, the Family complained that the resident was administered an antipsychotic without consent from the Family. The Resident had been administered 10 doses of [MEDICATION NAME] without consent from the Resident's Health Care Agent. The Facility indicated a medication error was completed, staff were educated and that the grievance was resolved and indicated Family understood on 5/10/17. There was no long term plan to prevent further medication errors - On 7/2/17, the Resident reported medications that were not his/hers were left in room. Staff education was completed with medication and that although the grievance initialed as resolved there was no date and no indication the Resident was notified of resolution. There was no long term plan. - On 7/7/17, three Residents (not identified) reported staff's perfume was strong and causing exacerbation of allergies and other symptoms (according to Residents). Medications that were not his/hers were left in room. The Facility said general education was completed on policy of perfumes while working and that monitoring would be conducted. The executive director signed the resolution on 8/8/17 (more than a month after received) and there was no indication the 3 residents were notified of the resolution; there was no indication that the Facility addressed the concern related to medication that was left at the bedside; and the Facility did not address that medication had been reported left at the bedside 5 days earlier. Furthermore, Surveyors had observed medications left on the bedside during the survey process. - During an interview with the State Ombudsman on 10/5/17 at 12:30 P.M., she said that she was visiting with Resident #3 (prior to meeting with the Survey Team) and observed a medication cup on the Resident's tray table. The Ombudsman said there was no Facility staff in the room and the cup contained what she thought was medication. The Surveyor met with the Resident on 10/5/17 at 12:35 P.M. The Resident was in bed and was eating his/her lunch meal. On the Resident's tray table were 2 empty medication cups. The Resident was asked about the 2 medication cups and the Resident said that the nurse had left his/her medication on his/her night table to take when he/she ate lunch. The Resident said the medication was Calcium Acetate that he/she takes with meals. The Resident said that staff leave his/her medication for him/her so that it is there when he/she gets his/her meals. - On 10/13/17 from 8:45 A.M. through 9:30 A.M., 2 medications ([MEDICATION NAME] solution 0.1% ([MEDICATION NAME] used to treat allergic [MEDICAL CONDITION] and symptoms of itchy, red swollen and watery eyes), instill 1 drop in each eye, twice daily and Artificial Tears solution (artificial tear and lubricant), instill 2 drops in each eye, four times daily), were observed on the Resident's tray table in his/her room. At the time of the observation the Nurse admitted to leaving the medication unattended. The Director of Nurses subsequently said that the Nurse did not leave the medication at the bedside and no action plan was provided. - On 8/7/17, the Resident complained that he/she had received care from a CNA who was not suppose to care for him/he because the CNA had hurt his/her breast area and left him/her naked twice. The resolution was to meet with CNA, nurse and note on assignment that CNA not provide care. The grievance was signed as resolved and indicated the it was agreed to by the Resident on 8/8/17. The grievance indicated that the CNA was not to care for the Resident due to previous complaints, the grievance fails to cross reference the grievances or ensures that there is a long term plan to prevent the incident from reoccurring. - On 8/14/17, the Resident's son reported that staff missed three dressing changes of a wound. The Facility indicated that the Treatment record indicated that 2 not 3 dressing changes were not done. The grievance indicated a message was left with the family and apprised of the information and resolution on 8/17/17. The grievance was left incomplete and no evidence of a long term plan to ensure the Resident received all treatments as ordered. - On 8/18/17, the Resident reported missing 2 bath towels. The plan was to notify laundry, but there was no resolution and the form was not dated. - On 8/18/17, the Resident (#4) reported being threatened by staff after he/she attempted to stop the CNA from making sexual aggressive statements toward another Resident. The grievance was not addressed and not reported to the Department of Public Health as required. Resident #4 was interviewed on 10/12/17 at 11:30 A.M. and said he/she had filed the grievance but that nothing ever gets done about complaining. The Resident said he/she asked that the CNA not care for him/her but that the CNA is assigned to the Unit he/she lives on and says he/she is a terror. - On 8/25/17, the Resident's Family reported that call lights not answered on 3:00 P.M. to 11:00 P.M., requested medications whole when mixed in applesauce so he/she can check them, as staff administering both 6:00 P.M. and 9:00 P.M. medications at the same time, requested a hearing consult for Resident, and asked that the hoyer pad be changed as was too small for Resident. The facility outlined an action plan which included education on call lights with staff, new directions for medication administration, no evidence scheduled medications being administered together and a referral was made to social service for hearing evaluation. The grievance was considered resolved on 8/30/17 and staff left a message for the Family, but did not indicate who they had contacted and communicated the plan or had a long term plan. - On 8/30/17, the Resident's Family reported missing clothing, often finds the Resident in wet adult briefs, reports Resident is unkempt, hair not combed, dentures not in and dirty laundry being placed back in the Resident's drawers. The Family reported that they had spoken to the CNA and multiple staff on 2 shifts with no results. The grievance form indicated that the grievance was not addressed and that no communication had been conducted with the Family. - On 9/4/17, the Resident's Family observed the nurse administering medications. The medications were to be crushed and the nurse was attempting to administer the medications whole. The Family said the Resident was lethargic and asked the nurse what was in the medication cup. The nurse said [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antipsychotic). The grievance indicated there was no order for the [MEDICATION NAME] and that the Family was upset because the nurse made light of the incident, was casual and careless during incident. The Family was concerned as the nurse was from an agency and felt that the nurses do not know the Resident. The Family said that they had called the Director of Nurses (DON) multiple times and had not received any returned telephone calls. The grievance indicated that they reviewed the medications, educated the nurse, would not assign the nurse to the Resident's unit in the future and resolved the incident with the Family on 9/5/17. The Facility did not address the concerns specifically and doesn't include plan to supervise staff and/or notify agency of the concern. 2. Resident #1 asked to speak with the Surveyor on 10/8/17 at 11:15 A.M. and said that the staff were miserable, mean, rude and had made everything he/she did an issue. The Resident had a list of concerns and complaints that he/she had tried to address with the Facility, but had given up because the Staff make him/her feel that he/she is the problem and this increases his/her anxiety and had made him/her feel trapped, hopeless and depressed. The Resident said he/she had complained about; - call bells not being answered and was afraid that if something happen to him/her no one would come. - Nurse #2 told another nurse that if the Resident wanted to go to the hospital the Resident would have to call for an ambulance him/herself, - Resident #1 said he/she saw 2 staff dragging a Resident by arms and feet dragging down the hall. - CNA heard slapping Resident #1's roommate. - and fear of reporting any concerns because staff are intimidating. On 10/8/17 at 11:15 A.M., the Surveyor reported to the Administrator that the Resident felt hopeless and was fearful of staff. On 10/10/17 at 8:00 A.M. the Administrator said that Social Worker #1 (SW #1) had met with the Resident on 10/9/17 and that the Resident felt supported and safe. He said he spoke with Nurse #2 and she had no idea what the Resident was talking about. The Administrator said Nurse #2 can come across loud and intimidating to some. During interview with SW #1 on 10/10/17 at 8:45 A.M., she said she met with the Resident and the Resident shared the information about his/her feelings of anxiety and hopelessness. She said that she had not been active in the Resident's care as she had just increased his/her hours at the Facility. SW #1 did not know the Resident's actual history ([MEDICAL CONDITION] and potential problems associated with his/her anxiety and depression) but planned on following up to ensure the Resident felt safe and cared for. SW #1 said that she had offered a room change to another unit. The SW said that she had heard that the Nurse had attempted to send Resident #1 on a Section 12 for having cigarettes in room. SW #1 said that it was concerning. The Resident was not moved off the unit until 1012/17 and on 10/13/17, observations indicated the Resident's belongings were left on the floor unpacked in suitcases. The Resident said due to limited shoulder range he/she could not reached down to unpack them. On 10/11/17 at 4:00 P.M., Resident #1 and his/her Family met with the Surveyor. The Family supported the allegations made by the Resident and said that he/she was also had concerns about the Resident's care. The Family said the staff were intimidating. The Family said they had reported their concerns to the Facility and outside agencies, but had felt it had made it worse. The Family said that the staff did not listen to the Resident care needs and have told the Resident to call 911 if he/she felt needed to go to the hospital. The Resident and Family were agreeable to meet with the Facility Staff. The SW, Administrator and Director of Nurses (DON) was asked to meet with the Resident and Family. Following the meeting with the Family and Facility Staff, the Surveyor asked for an update. On 10/19/17 at 11:30 A.M., it was determined that the meeting with the Family and Resident's voiced issues had not been addressed. The Administrator had not taken down any notes and the DON did not attend. The SW had notes but had not followed up with any additional information and there was no change to the Resident plan of care to ensure the Resident felt safe and was receiving services that promote and address her depression and anxiety. The Resident was interviewed and said that other than the room change no one from the no staff had met with him/her about addressing his/her needs to ensure he/she feels safe and does not feel hopeless, fearful or trapped. 3. Resident #4 was admitted to the Facility in 5/2015 with [DIAGNOSES REDACTED]. Review of Resident#4' most recent Quarterly Minimum Data Set (MDS) assessment, dated 7/25/17 indicated the Resident required extensive assistance with all ADLs (Activities of Daily Living). The BIMS (Brief Interview for Mental Status) indicated Resident #4 scored a 13 out of 15, indicating the Resident was cognitively intact. Resident #4 participated in the Quality of Life Assessment/Group Interview, held on 10/5/17 at 10:30 A.M., and said he/she wanted to report instances that he/she felt threatened and that the Facility Administration did little to reassure him/her of being protected. The Resident said he/she had filed a number of grievances and that there had been no follow-up. Review of the Grievance Log from 7/2016 through 10/2017 indicated that Resident #4 had filed 3 grievances, they were as follows:. - On 6/4/17, the Resident alleged that CNA (Certified Nursing Assistant) #5 had been rude to him/her and did not help the Resident when was asked. The action plan was to educate CNA #5 in customer service, tone of voice and resident perception. - On 8/18/17- Resident #4 reported that he/she observed CNA #5 verbalizing sexual remarks towards a male Resident. Resident #4 reported that he/she asked CNA #5 to stop her behavior towards the other Resident. The Resident said the CNA prevented the Resident from leaving the area by putting her foot deliberately under the wheel of the wheelchair. The Resident said he/she felt trapped and after three requests for the CNA to remove her foot the Resident pushed him/herself out of the way. The Resident said the CNA told him/her that I should worry about myself not the other . resident. The grievance was incomplete and did not include an investigation or action plan and not reported to the Department of Public Health as required. - On 08/30/17, Resident #4 reported to Nurse #3 that CNA #5 had verbally threatened to throw Resident #4 down the stairs, and said she could do whatever she wanted to Resident #4 and no one would ever know, or words to that effect. The Facility's completed an internal investigation and indicated that the allegation could not be substantiated, but that the Facility would ensure that CNA #5 did not provide care to Resident #4, to the extent possible, and when necessary, CNA #5 would ensure another care partner accompanied her. The plan did not include how they would supervise CNA #5. Additional review of Resident #4's medical record indicated that the nursing notes dated 7/14/17, 7/20/17 and 7/25/17 had documented several conflicts, but did not specified who, what and when. They are as follows: - On 7/14/17, the note indicated the had a verbal disagreement with a CNA, in which the CNA stated the Resident struck her. The note indicated the Resident was spoken to and the CNA was recommended to take the Resident off assignment. There was no further documentation about the situation for review. - On 7/20/17, the nurse's note indicated the Resident had a personality conflict with the assigned CNA. The note indicated the situation resulted in an uncomfortable situation, but did not specify who was uncomfortable. The Resident requested another staff to care for him/her and was annoyed when not addressed. - On 7/25/17, the nurse's note indicated the Resident expressed concern that the CNAs do not know enough about his/her condition and has been having accidents at night. The Resident told staff he/she was frustrated. The staff indicated that the Resident would be placed on a 2 hour toileting schedule. The note indicated the Resident voiced concerns about the plan as he/she had to be completely relaxed to void. Review of the grievance log indicated no documentation filed on Resident's behalf for the incidents dated 7/14/17, 7/20/17 or 7/25/17. During interview on 10/12/17 at 11:30 A.M., Resident #4 requested the interview not be conducted in his/her room. Resident #4 said that his/her roommate was due back to the room and had asked him/her to not involve him/her in the interview with the Surveyors. Resident #4 said that the Facility staff had threaten the Resident and roommate if they complained to the Survey team. The Resident said the CNAs said that once they (the Surveyors) were gone things would go back to the way they were. During the interview the Resident reported the three allegations, plus additional concerns. Resident #4 said that staff acted like we (the Residents) were non-people and they don't even acknowledge that we are human. Resident #4 said that he/she feels especially threatened and intimidated by CNA #5 and CNA #6. Resident #4 said that the 2 CNAs together were total terror. Resident #4 said that he/she had filed multiple formal completes, but that it was pointless. The Resident said that that after reporting a complaint the staff denied the incident and backed each other up, that nothing ever gets done about anything. During several interviews with the Ombudsman on 10/11/17 at 8:00 A.M. and on 10/19/17 at 2:30 P.M., she said that the Facility's assigned Ombudsman did meet with Resident #4 and had assisted with the Resident's grievances. She said that she was aware of at least 2 formal meetings held with the Resident, Family, Ombudsman and Staff on 7/11/17 and 8/4/17. She said that the Director of Nurse's (DON) participated and that the Administrator only stuck his head into one meeting and ask the Resident's Family a question and said he was very concerned about issues and left. The Ombudsman said that there was no follow up from those meetings and although several grievances were tracked in the log book, there was no information about the grievances filed on behalf of the Resident by the Ombudsman. 4. The Ombudsman said on 10/11/17 at 8:00 A.M. and on 10/19/17 at 2:30 P.M., she said that there had been multiple concerns brought to the Administration staff. She said that she was aware that the Facility had staffing concerns that included a high agency pool and that systems were not in place to ensure oversight and follow through with complaints. The Ombudsman said that she had received several formal grievances and had brought them to the attention of the Administrator. She said one of the grievances was also sent to the Facility. The grievance indicated that residents were not receiving care and that staff took long breaks in and outside of the facility. The grievance gave some specifics. She said when she met with the Administrator, after providing the Facility time to address the grievance, the Administrator opened the letter with the grievance in front of her. The Ombudsman said she followed with the Facility's Administration several weeks later and again it was reported that the Facility had not addressed the grievance. The Ombudsman provided a copy of the grievance and it was determined that the Facility had not followed their grievance process. During multiple meetings with the Administrator, the grievance identified by the Ombudsman was discussed with the Administrator. The Administrator said he had been aware of the grievance for several months, but could not provide documentation that he or his/designee responded to the grievance. During the course of an interview, the Administrator asked the Survey Team for a copy of the grievance. 5. During the Quality of Life Assessment/Group Interview, held on 10/5/17 at 10:30 A.M., 19 residents who resided on 3 of the 4 Units participated. The consensus of the Group Interview indicated that the Resident's felt the Facility Staff treatment to the residents was disrespectful and intimidating. The Residents said they had experienced instances in which the Facility Staff yelled at them for using their call lights and threatened them to not report their complaints. The Residents said that the Administration disregarded their complaints and that the staff (especially agency staff) made up rules as they went along and did not allow them to report complaints. The group consensus indicated that they no longer filed grievances because they did not receive any resolution from the Administration staff. The Resident's said that the grievance forms were not available and if they did report a grievance to staff they did not know if it ever went any further. Several Residents participating in the group said the had filed multiple grievances. See F 244. Social Worker #1 was interviewed multiple times throughout the dates of survey. Social Worker #1 said that since increasing her hours in September 2017, she had received more complaints, concerns, and allegations from residents regarding instances of needs not being met, abuse or neglect, and poor quality of care. Social Worker #1 said she was responsible for the grievances and tracking of the grievances. She said that she had no formal training and was aware that the tracking log was not up to date. She also said that many complaints that she received had not been entered into the grievance process. She said she initially would pass the information onto the Administrator, but many of the residents had requested she not do that as they were afraid of retaliation from Facility staff. Social Worker #1 said residents reported being fearful of staff, that CNAs would stick their tongues out at residents, glare at them, laugh at them, would bully and intimidate residents by making statements such as there's no one here to help you but us, or words to that effect. Social Worker #1 said residents' concerns and complaints were often minimized or discounted, and were often considered customer service issues.

Based on records reviewed, observations and interviews, for 3 of 28 sampled residents (#4, #16 and #22), the facility failed to prevent ongoing physical and mental abuse, isolation, and neglect. Findings include: - On 08/18/17, Resident #4 was allegedly threatened by staff after he/she attempted to stop a Certified Nurse Aide (CNA) from making sexual aggressive statements toward another resident. - On 08/30/17, CNA #5 allegedly threatened to throw Resident #4 down the stairs, and told Resident #4 that she (CNA #5) could do whatever she wanted to Resident #4 and no one would ever know, or words to that effect. The Facility's internal investigation indicated that the allegation could not be substantiated, but that the Facility would ensure that CNA #5 did not provide care to Resident #4, to the extent possible, and CNA #5 would ensure another care partner accompanied her when necessary. - On 06/01/17, Nurse #4 allegedly pulled down her own pants to show Resident #22 a scar, and Resident #22 was uncomfortable with what he/she perceived as inappropriate behavior by Nurse #4. The Facility's internal investigation indicated that the allegation was substantiated, and Nurse #4 no longer worked at the Facility. However, review of Facility staffing schedules indicated Nurse #4 returned to work at the Facility prior to Resident #22's discharge from the Facility. - On 10/10/17, Resident #16 alleged that CNA #2 did not provide him/her with adequate care, particularly regarding personal hygiene needs, which was an ongoing issue. The Administrator met with Resident #16 on 10/11/17 regarding the allegation, and asked Resident #16 what he/she thought would be appropriate discipline for CNA #2. Resident #16 said he/she did not think that was appropriate, and felt the question put undue pressure on him/her. - Social Worker #1 said that since September 2017, she had received more complaints, concerns, and allegations from residents regarding instances of needs not being met, abuse or neglect, and poor quality of care. Social Worker #1 said she initially passed the information onto the Administrator, but many of the residents requested she not do that as they were afraid of retaliation from Facility staff. Social Worker #1 said residents reported being fearful of staff, that CNAs would stick their tongues out at residents, glare at them, laugh at them, would bully and intimidate residents by making statements such as there's no one here to help you but us, or words to that effect. Social Worker #1 said residents' concerns were often minimized or discounted, and were often considered customer service issues instead of allegations of abuse or neglect. - The Quality of Life Assessment/Group Interview, held on 10/5/17 at 10:30 A.M., was attended by 19 residents representing 3 of 4 nursing care units at the Facility. The residents in attendance said they felt disrespected and intimidated by Facility Staff. The attendees said they were yelled at for using their call lights, were threatened in response to complaints, that administration disregarded their complaints, and that the staff (especially agency staff) made up rules and did not allow them to report complaints. The residents said they no longer filed grievances because they did not receive any resolution from administrative staff. Findings include: 1. During the Quality of Life Assessment/Group Interview, Resident #4 said he/she wanted to report instances when he/she felt threatened and the Facility administration did little to reassure him/her of being protected. Resident #4 said he/she had filed a number of grievances and that there had been no follow-up. Resident #4 was admitted to the Facility in May 2015 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 07/25/17, indicated that Resident #4 required extensive assistance with all ADLs (Activities of Daily Living), was cognitively intact, exhibited some symptoms of depression and self-deprecation (undervaluing oneself), and was provided consistent staff. The Grievance Log, dated from 07/2016 through 10/2017, indicated that Resident #4 had filed 3 grievances: - On 06/04/17, Resident #4 alleged that CNA #5 was rude to him/her and did not help when was asked. The action plan was to educate CNA #5 in customer service, tone of voice and resident perception. - On 08/18/17, Resident #4 reported that he/she heard and saw CNA #5 make sexual remarks towards a male resident. Resident #4 said that when he/she asked CNA #5 to stop her behavior towards the other resident, CNA #5 deliberately put her foot under the wheel of Resident #4's wheelchair to prevent him/her from leaving the room. Resident #4 said he/she felt trapped and had to ask CNA #5 three times to remove her foot so Resident #4 could leave. Resident #4 said CNA #5 told him/her that I should worry about myself and not the other resident, or words to that effect. - On 08/30/17, Resident #4 reported to Nurse #3 that CNA #5 verbally threatened to throw Resident #4 down the stairs, and said she could do whatever she wanted to Resident #4 and no one would ever know, or words to that effect. The Surveyor interviewed Resident #4 at 11:30 A.M. on 10/12/17. Resident #4 requested the interview not be conducted in his/her room as his/her roommate did not want to be present during the interview with the Surveyor. Resident #4 said Facility staff had threatened Resident #4 and his/her roommate if they complained to the Survey team. Resident #4 said the CNAs said that once the Surveyors were gone, things would go back to the way they were. Resident #4 confirmed that he/she had filed the three grievances as observed by the Surveyor in the Grievance Log, and said he/she had also reported many other concerns. Resident #4 said staff acted like the residents were non-people, and did not acknowledge that the residents were human. Resident #4 said he/she felt especially threatened and intimidated by CNA #5 and CNA #6. Resident #4 said that when CNA #5 and CNA #6 worked together, they were total terror, or words to that effect. Resident #4 said he/she filed multiple formal complaints, but that it was pointless because staff denied the reports and backed each other up, and nothing ever got done about anything. Resident #4 said he/she had asked for CNA #5 to not care for him/her anymore, but because there was insufficient staffing, CNA #5 was assigned to his/her unit. Resident #4 said CNA #5 did not provide direct care, but he/she remained fearful of CNA #5 because she did not like Resident #4. Resident #4 said that as a result of the increased stress of living in the Facility since July 2017, he/she had increased his/her appointments with his/her psychiatrist. Resident #4 said he/she had reported concerns and allegations to the Facility staff, his/her psychiatrist and the Ombudsman on a weekly basis. Resident #4 said he/she did not ask that his/her concerns not be shared with Facility administration, but did not know if there was follow through by the people he/she reported his/her concerns to. The Surveyor interviewed the Ombudsman at 8:00 A.M. on 10/11/17, and at 2:30 P.M. on 10/19/17. The Ombudsman said there had been multiple concerns brought to the administration staff, including staffing concerns that included a high agency pool, and that systems were not in place to ensure oversight and follow through with complaints. The Ombudsman said Resident #4 and his/her family scheduled several meetings with administrative staff from 07/11/17 through 08/04/17 to discuss Resident #4's complaints. The Ombudsman said the Director of Nurses (DON) met with them, but the Administrator only stuck his head into one meeting to ask a question, said he was very concerned about issues, and left. The Ombudsman said there was no follow up from those meetings. The Surveyor interviewed Resident #4's Psychiatrist at 10:10 A.M. on 10/19/17. The Psychiatrist said he had treated Resident #4 for many years. The Psychiatrist said Resident #4 voiced concerns to him that Facility staff was not attending to his/her care needs and reported other conflicts with staff. The Psychiatrist said he encouraged Resident #4 to go through the appropriate channels to resolve the problems, but felt that the Facility's response was not adequate. The Psychiatrist said he made written recommendations, but had not spoken directly to the Facility staff or any other agency. The Psychiatrist said Resident #4's family had met with Facility administration about staff not attending to physical needs, staff telling Resident #4 that he/she could do things Resident #4 was not capable of doing because of his/her medical/physical condition, and staff's attitude towards Resident #4. The Psychiatrist said he was told the plan was to move Resident #4 to another floor, but felt this would increase Resident #4's anxiety. The Psychiatrist said Resident #4 feared retribution if he/she continued to complain. The Surveyor interviewed CNA #5 at 12:15 P.M. on 10/19/17. CNA #5 said she was trained on abuse via a computer and video. CNA #5 said the definition of abuse was an intentional act used to hurt a resident. CNA #5 denied she ever abused a resident, or of being accused of abuse by a resident. CNA #5 said Resident #4 made up stories about her because she encouraged residents to do things for themselves. CNA #5 said she had asked to not take care of Resident #4 because of their differences. CNA #5 said that following the the allegation on 08/30/17 that she threatened to push Resident #4 down the stairs, she did not receive any discipline, was not suspended, and did not receive additionally training on abuse, customer service or caring for residents with behaviors because she was not guilty, or words to that effect. The Administrator, DON, Regional Nurse Consultant and Vice President of Operations were interviewed at multiple times throughout the dates of survey. The Administrator, DON, Regional Nurse Consultant and Vice President of Operations were informed of Resident #4's fear of intimidation, fear of retribution, increased emotional stress which led to increased psychiatric services, and that Resident #4 said that it was pointless to report any additional complaints because the Facility did not do anything. The Administrator, DON, Regional Nurse Consultant and Vice President of Operations said they had educated staff on customer service, had suspended accused staff persons as per Facility policy, had resolved grievances, and/or had completed investigations. However, the Administrator, DON, Regional Nurse Consultant and Vice President of Operations could not provide documentation regarding the education of staff on customer service, suspension of accused staff persons, the resolution of grievances, or the completion of investigations. 2. Resident #22 was admitted to the Facility in May 2017. The Facility's internal investigation indicated that on 06/01/17, it was reported to the Director of Activities that Nurse #4 pulled down her own pants to show Resident #22 a scar, and that Resident #22 was uncomfortable with what he/she perceived as inappropriate behavior by Nurse #4. The Facility's internal investigation and Resident #22's clinical record indicated that, even though any exposed body parts were not identified, Resident #22 reported the incident as unwelcome sexual behavior by Nurse #4, and he/she felt taken back, betrayed and violated by Nurse #4's actions. Social Worker #1's note, dated 06/09/17, indicated that Resident #22 reported on 06/07/17 that he/she was still affected by the incident and was depressed. The note indicated that the administration was aware of the allegation and were taking steps to investigate and address the concern. The investigation indicated that the action plan was that Nurse #4 would not work at the Facility. However, Resident #22's clinical record and Facility nursing staff schedules indicated that Nurse #4 provided direct care to Resident #22 on 08/04/17, 08/05/17 and 08/17/17. The Surveyor interviewed the Human Resources staff at 11:00 A.M. on 10/19/17. The Human Resource staff said Nurse #4 did not work at the Facility for a period of time, but was reinstated on 07/21/17, which was prior to Resident #22's discharge from the Facility on 08/18/17. 3. Resident #16 was admitted to the Facility in February 2017. The Quarterly MDS, dated [DATE], indicated that Resident #16 was cognitively intact, and required the extensive assistance of two or more persons for toileting needs and bed mobility (the ability to change position in bed), the physical assistance of two or more persons for personal hygiene, and was fully dependent for bathing needs. The Surveyor interviewed Resident #16 at 9:30 A.M. on 10/13/17. Resident #16 said that on 10/10/17, he/she reported to Social Worker #1 that CNA #2 had not provided adequate care to him/her the night before (10/09/17). Resident #16 said CNA #2 was hostile and wiped him/her twice across the back area instead of providing a bed bath. Resident #16 said the Administrator met with him/her the following day (10/11/17), and after he/she told the Administrator what had occurred with CNA #2, the Administrator asked him/her how he/she thought CNA #2 should be disciplined. Resident #16 said that because inadequate care was an ongoing issue with CNA #2, he/she wanted to tell the Administrator to fire CNA #2, but said it was not his/her job to make that decision and felt pressured by the question. The Grievance Form, dated 10/09/17, indicated that Resident #16 was upset by care provided by CNA #2, and described repeated incidents of CNA #2 telling him/her that she could not help him/her due to (her) injury or illness. Social Worker #1 said she spoke with Resident #16 on 10/10/17, who reported to her that on the previous evening, CNA #2 had not washed him/her properly. Social Worker #1 said Resident #16 reported that CNA #2 always had some excuse as to why she could not provide care, and would tell other staff not to provide care to Resident #16 either. Social Worker #1 said Resident #16 told her that he/she was really concerned about not getting care as he/she had a coccyx (tailbone area) wound. Social Worker #1 said she did not notify the Administrator of Resident #16's allegation until the following day (10/11/17). Social Worker #1 said she knew she should have notified the Administrator right away, but became busy and forgot. On 10/13/17 at 9:30 A.M., the Surveyor observed a reddened and excoriated stage I (an observable pressure-related alteration of intact skin) on Resident #16's right buttock, and a stage II (partial thickness skin loss) of the left buttock. The Surveyor interviewed the DON at multiple times on 10/12/17. The DON said she was unaware of the two areas of altered skin integrity on Resident #16's buttocks. The Surveyor interviewed the Administrator at multiple times throughout the dates of survey. The Administrator said he met with Resident #16 in response to his/her concerns about CNA #2. The Administrator said he considered Resident #16's report of the incident as the provision of incomplete care, or words to that effect. 4. The attendees of the Quality of Life Assessment/Group Interview said they no longer filed grievances as a group or individually because they did not receive any resolution from the administration staff. The attendees said the administration disregarded their complaints. During the Quality of Life Assessment/Group Interview, held on 10/5/17 at 10:30 A.M., 19 residents who resided on 3 of the 4 Units participated. The consensus of the Group Interview indicated that the Resident's felt the Facility Staff treatment to the residents was disrespectful and intimidating. The Residents said they had experienced instances in which the Facility Staff yelled at them for using their call lights and threatened them to not report their complaints. The Residents said that the Administration disregarded their complaints and that the staff (especially agency staff) made up rules as they went along and did not allow them to report complaints. See F 244

Based on records reviewed, observations and interviews, for 4 of 28 sampled residents (Resident #1, Resident #2, Resident #4, and Resident #22), the facility failed to report alleged abuse and/or neglect, to conduct thorough investigations, and failed to protect residents from potential further abuse or neglect. - The Facility failed, for 3 of 28 sampled residents (Resident #1, Resident #2, and Resident #22), to ensure that reports of alleged abuse and/or neglect were reported to the Department of Public Health (DPH) within two hours as required. - The Facility failed, for 2 of 28 sampled residents (Resident #1 and Resident #2) to conduct thorough investigations of alleged incidents of abuse and neglect, including interviewing any persons who might have knowledge of the alleged incident, and obtaining written statements. - The Facility failed, for 2 of 28 sampled residents (Resident #4 and Resident #22), to protect residents from accused staff persons following reports of alleged abuse. Findings include: 1. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that an initial report of allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin, and misappropriation of resident property must be made within two hours to the State Survey Agency (DPH) and law enforcement. A. The Surveyor interviewed Resident #1 at 11:50 A.M., 12:40 P.M. and 1:45 P.M. on 10/08/17. Resident #1 requested that the interview be conducted behind closed doors as he/she was afraid staff would listen, and he/she did not feel safe in facility and was scared. Resident #1 said Facility staff was miserable and said he/she experienced and witnessed situations that caused him/her to feel staff was rude and mean. Resident #1 said Nurse #2 told Resident #1 to call 911 himself/herself if he/she did not feel well and wanted to go to the hospital. Resident #1 said Nurse #2 controlled the unit in a vindictive manner. Resident #1 said Nurse #2 openly yelled at residents (including Resident #1), Family and Staff. Resident #1 said the unit was very tense and he/she was scared to complain. Resident #1 also said she heard a CNA (Certified Nurse Assistant) slap his/her roommate (Resident #2). Resident #1 said he/she heard a slapping noise while the CNA (identified by the Facility as CNA #1) cared for Resident #2. Resident #1 said she heard CNA #1, say don't hit me, or words to that effect. Resident #1 said she heard another slapping noise, heard Resident #2 say ouch, you hit me, or words to that effect, and heard CNA #1 respond well, you hit me first, or words to that effect. Resident #1 said he/she knew the CNA's name and said the CNA was currently employed at the Facility. Resident #1 said his/her family was aware of the CNA slapping the roommate, and said that he/she reported the incident to other people. Resident #1 said he/she was afraid to report the incident to staff because he/she and his/her Family had tried to report concerns in the past, but nothing was done. Resident #1 said he/she thought staff was afraid of Nurse #2 also. Resident #1 said he/she spoke with the Surveyors because he/she did not want to hold onto the fears anymore and wanted to talk to someone. Resident #2 could not be interviewed due to cognitive deficits. The Surveyor interviewed the Administrator at 12:00 P.M. on 10/08/17. The Surveyor asked the Administrator to speak with Resident #1 as he/she reported being afraid of the staff and had concerns about the care he/she received. At 12:15 P.M. on 10/08/17, the Administrator said Resident #1 reported that he/she heard Resident #2 being slapped. The Administrator said Resident #1 said the incident occurred 2 months prior, and that he/she heard it, but had not witnessed it and had not reported it to anyone. The Administrator said Resident #1 only provided the first name of the staff person he/she alleged slapped Resident #2. The Surveyor told the Administrator that Resident #1 also reported a number of allegations that included neglect, intimidation and was fearful of staff, and that he/she was scared. The Administrator said Resident #1 had mental illness and had not reported any other allegations. At 12:40 P.M. on 10/08/17, Resident #1 said he/she reported the slapping incident with Resident #2 and the CNA, including a description and name of the CNA. Resident #1 also said he/she reported the treatment he/she received from Nurse #2 including: rudeness, meanness: being told to call 911 him/herself when not feeling well, making him/her afraid; Nurse #2 intimidating him/her and yelling at him/her when he/she sat at the nurses station; and, Nurse #2 telling him/her to mind his/her own business when Resident #1 asked to sit with a dying resident that asked for Resident #1. Resident #1 said that on another occasion, staff found a resident dead on the floor and laughed at how long that resident had been lying there. Resident #1 said he/she witnessed two staff drag a yelling resident down the hall. Resident #1 said these actions were intimidating and frightened him/her. Resident #1 provided his/her written documentation of the alleged incidents, and said he/she told the Administrator the same concerns as those addressed with the Surveyor. At 2:00 P.M. on 10/08/17, the Administrator said Resident #1 did not share any allegations with him except for the incident in which the CNA allegedly slapped Resident #2. The Administrator said Resident #1 was a problem and he would need to figure out the identity of the CNA. On 10/10/17 at 8:00 A.M., the Administrator said Social Worker #1 met with Resident #1 and received a report from Resident #1 of Resident #2 being slapped. The Surveyor interviewed Social Worker #1 at 8:45 A.M. on 10/08/17. Social Worker #1 said she met with Resident #1, who reported the incident of Resident #2 being slapped, Resident #1's fears of Nurse #2, and his/her fear that staff could not adequately care for him/her. Social Worker #1 said Resident #1 had mental illness, but then said she had received more complaints, concerns, and allegations from other residents regarding instances of needs not being met, abuse or neglect, and poor quality of care. Social Worker #1 said she initially passed the information onto the Administrator, but many of the residents had requested she not do that as they were afraid of retaliation from Facility staff. At 4:00 P.M. on 10/11/17, the Surveyor met with Resident #1 and his/her Family Member. The Family Member affirmed the allegations made by Resident #1, and said he/she was also intimidated by the staff on the unit. The Family Member said she reported her concerns to the Facility and outside agencies, but felt that her reports made the intimidation of residents by staff worse. The Family Member said staff did not listen to Resident #1, and had told Resident #1 to call 911 if he/she felt he/she needed to go to the hospital. At 11:30 A.M. on 10/19/17 at 11:30 A.M., the Facility was unable to provide any documentation of any investigation into the concerns voiced during the meeting with the Family Member and Resident #1. The Administrator said he had not taken down any notes, and Social Worker #1 said she had notes but had not followed up with any additional investigation. Resident #1 said no staff had asked him/her any additional questions about his/her fears. There was no documentation at the time of survey that Resident #1's allegations were reported to the DPH within 2 hours as required, including the allegation of the abuse of Resident #2, despite the Administrator's statement that he was very concerned about the issues and that he deals with all issues that he hears about and sees. B. The Facility's internal investigation indicated that on 06/01/17, Resident #22 reported to the Director of Activities that Nurse #4 pulled down her own pants to show Resident #22 a scar, and Resident #22 was uncomfortable with what he/she perceived as inappropriate behavior by Nurse #4. The internal investigation and Resident #22's medical record indicated that he/she described the incident as unwelcome sexual behavior by an agency Nurse (#4), and that Resident #22 felt taken back, betrayed and violated by Nurse #4's actions. Social Worker #1's progress note, dated 06/09/17, indicated that Resident #22 reported on 06/07/17 that he/she was still affected by the incident and was depressed. The progress note indicated that administration was aware of the allegation and were taking steps to investigate and address the concern. The internal investigation indicated that the Director of Activities notified the Director of Nurses (DON) on 06/01/17. The investigation indicated that the Interim DON was notified of the alleged incident on 06/07/17, but that it was not reported until 06/09/17, 8 days later. Resident #22 could not be interviewed as he/she no longer resided at the Facility at the time of survey. The Interim DON could not be interviewed as she no longer worked at the Facility at the time of survey. There was no documentation at the time of survey that Resident #22's allegation was reported to the DPH within 2 hours as required. 2. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, indicated that all investigations shall include interviews of employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident. The Policy indicated that written statements from involved parties may be requested. The Administrator said he was primarily responsible for conducting investigations into allegations. The Administrator said he asked staff for written statements, but did not always get them. A. The Facility's internal investigation into Resident #1's allegations of abuse and mistreatment by Nurse #2 included a written statement from Nurse #2, but did not include written statements from or interviews with, employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident. There was no documentation at the time of survey that the Facility interviewed or obtained written statements from any other persons who might have knowledge of the alleged incident. B. The Facility's internal investigation into the allegation that CNA #1 slapped Resident #2 did not include written statements from or interviews with, employees, visitors, residents, volunteers and vendors who might have knowledge of the alleged incident, including the accused CNA (CNA #1). There was no documentation at the time of survey that the Facility interviewed or obtained written statements from any other persons who might have knowledge of the alleged incident. 3. The Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy, effective 05/03/17, did not include the protection of residents or staff following the report of alleged violations including abuse, neglect, and mistreatment. The Administrator said that the Facility did not necessarily have a sufficient number of staff to shuffle people around, or words to that effect, when a resident complained about a staff person. A. The Surveyor interviewed Resident #4 at 11:30 A.M. on 10/12/17. Resident #4 said that on approximately 08/31/17, CNA #5 pushed his/her wheelchair into the wall of the elevator, and then whispered into Resident #4's ear that she wanted to push Resident #4 down the stairs, and that CNA #5 could do whatever she wanted to Resident #4 and no one would ever know, or words to that effect. Although the Facility's internal investigation indicated that Resident #4 had a history of [REDACTED].#5, and had requested that CNA #5 not provide care to him/her, there was no documentation in Resident #4's clinical record that he/she had a history of [REDACTED]. The Facility's internal investigation indicated that the Facility would ensure that CNA #5 did not provide care to Resident #4, to the extent possible, and when necessary, CNA #5 would ensure another care partner accompanied her. However, review of Facility schedules dated 09/27/17 through 10/19/17 indicated that CNA #5 was scheduled to work on Resident #4's unit for 15 of 23 days. There was no documentation at the time of survey that the Facility protected either Resident #4 or CNA #5 following an allegation of abuse. B. The Facility's internal investigation into the allegation of sexually inappropriate behavior by Nurse #4 towards Resident #22 included Nurse #4's written statement, which indicated that she pulled her pants down to show Resident #22 a scar. The investigation indicated that the allegation was substantiated, and that Nurse #4's nurse staffing agency was contacted and she no longer worked at the Facility. Resident #22's clinical record indicated that Nurse #4 provided direct care for Resident #22 on 08/04/17, 08/05/17 and 08/17/17. The Surveyor interviewed the Human Resources staff at 11:00 A.M. on 10/19/17. The Human Resource staff said Nurse #4 did not work at the Facility for a period of time, but was reinstated on 07/21/17, prior to the Resident #22's discharge. The Facility nursing staff schedules indicated that Nurse #4 returned to work at the Facility on Resident #22's unit, on 07/21/17. The schedules indicated that as of the dates of survey, Nurse #4 continued to work at the Facility, despite the Facility's action plan that she would no longer do so. There was no documentation at the time of survey that the Facility followed its own action plan of not having Nurse #4 work at the Facility, in an effort to protect Resident #22.

Based on record review, observations and staff interviews, the Facility failed for 1 Resident (Resident #10), to ensure: the staff discontinued using a laxative while the Resident was experiencing acute diarrhea from [MEDICAL CONDITION] infection, which resulted in an acute kidney injury, lethargy and a hospitalization for intra-venous fluid resuscitation. The total sample included 28 residents. Findings include: Resident #10 was admitted to the Facility in 5/2017 with the following Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) for 8/2017 indicates that the Resident is cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15, but can make his/her needs known. He/she requires extensive assistance from staff for bed mobility, dressing, eating, bathing, and is incontinent of bowel and bladder. The Resident did have weight loss, however dietary interventions were in place. The Resident was observed during the survey from initial tour on 10/4-10/10/17 on various shifts. The Resident appeared cachetic (with appearance of physical wasting with loss of weight and muscle mass due to disease), pale and constantly yelling out help me, help me. Review of the Monthly Bowel Record for 9/2017-10/2017 indicates that Resident #10 experienced diarrhea on the following dates and for 8 days prior to being sent to the hospital: - 9/9/17- large loose bowel movement and vomited moderate amount of undigested food-message left for MD- no follow-up/ no new orders documented. - 9/11- 1 episode of diarrhea - 9/13- 3 episodes of diarrhea - 9/14- 1 episode of diarrhea - 9/16- 2 episodes of diarrhea - 9/17- 3 episodes of diarrhea - 9/18- 2 episodes moderate diarrhea - 9/19- 1 episode of diarrhea and nursing note: continues with loose stools, decreased appetite, lethargy, skin dry and warm - MD notified and sent to hospital. Review of the Hospital Discharge Summary (dated 9/21/17) indicates that Resident #10 presented with onset of acute diarrhea and elevated white blood count. The Resident was complaining of abdominal pain, was hypotensive (blood pressure of 104/59) and showed an acute kidney injury with critical lab values of BUN 68 and Creatinine 1.94. (Blood/Urea/Nitrogen test can reveal whether kidneys may not be working properly. BUN normal range=7-24. Healthy kidneys filter creatinine and other waste products from your blood. Cr normal range=.7-1.4). The Resident's discharge [DIAGNOSES REDACTED]. Discharge medications indicate: [MEDICATION NAME] 125 mg. by mouth 4 times per day for 8 more days (total of 10 days), [MEDICATION NAME] (a stimulant laxative) tablets 2 by mouth at bedtime (hold until[DIAGNOSES REDACTED] resolves) and [MEDICATION NAME] (stool softener) 100 mg by mouth 2 times per day (hold until[DIAGNOSES REDACTED] resolves). The comment hold until[DIAGNOSES REDACTED] resolves, written upon hospital discharge (9/21/17), was not indicated on the Facility's MAR upon return. Review of the Medication Administration Record [REDACTED].

Based on record review, observation and staff and resident interviews, the Facility failed to provide necessary services to promote healing of pressure ulcers for 4 Residents (#3, #5, #26 and #28) out of a total sample of 28. Findings include: During the entrance meeting with Director of Nurses and Administrator on 10/4/17, the management team informed the survey team that the Unit Manager (UM) of the facility covered 4 of 4 nursing units, was the wound nurse who did weekly rounds with the Wound Care Specialists and measured the wounds. This same nurse also was responsible for the infection control program and staff education for newly hired personnel and ongoing education of the staff. On 10/4/17, the Facility initially reported that they had 3 pressure areas and 1 was Facility acquired. During the survey, the UM informed the Surveyors of 3 additional (new) pressure areas on 10/12/17 at 2:00 P.M. and with these 3 new findings, the facility had a total of 6 pressure areas and 5 were facility acquired. 1. For Resident #3, the Facility failed to promote skin integrity by not consistently implementing physician treatments as prescribed. Resident #3 was admitted in 3/2017 and had [DIAGNOSES REDACTED]. The Resident was admitted with a Stage 4 sacral pressure ulcer and received [MEDICAL TREATMENT] treatment three times per week. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 7/6/17, indicated the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status) (indicating the Resident was cognitively intact and was able to understand and be understood). The MDS indicated the Resident required extensive assistance in his/her transfers, mobility and was unable to ambulate. The MDS also indicated that the Resident was at risk for pressure ulcers. The plan of care plan for actual pressure ulcer was initiated on 4/11/17 and was last revised on 7/14/17. The goal was for the actual pressure ulcer (area not identified) will heal without complications and that the Resident will be free from further breakdown. The plan of care interventions included an air mattress, Norton scale, weekly skin inspections, diabetic foot care monitoring, left heel boot, podiatry consult, pressure reducing cushions, mattress, treatments as ordered and weekly wound assessments. The hospital discharge record dated 3/29/17, the Resident had an infected Stage 4 sacral pressure ulcer, a status [REDACTED]. The hospital discharge record indicated that the sacral decubitus be treated daily with [MEDICATION NAME] ointment (a sterile enzymatic [MEDICATION NAME] ointment), intravenous [MEDICATION NAME] (antibiotic) for 4 to 6 weeks (after hemodiaylsis and at [MEDICAL TREATMENT], three times per week). The Facility's admission assessments, (including nurse's notes dated 3/29/17), indicated that the Facility staff identified the sacral pressure ulcer. Following the Resident's admission, the staff obtained admission orders [REDACTED]. The physician's progress note dated 3/30/17 identified the sacral ulcer. On 4/6/17, the Staff completed a Weekly Skin Review and indicated that the Resident had a stage 4 sacral wound (although they documented the area as a coccyx wound not sacral), 7 cm by 5 cm by 4 cm deep. The assessment did not include any other description of the wounds other than the size. Review of the 4/2017 TAR (Treatment Administration Record), from 4/1/17 through 4/8/17, the nursing staff had not documented that they provided the ordered treatment ([MEDICATION NAME] ointment) to the sacral area for 8 days. On 4/8/17, the TAR indicated that the transcription of the [MEDICATION NAME] ointment was changed to include the ointment be applied on sterile gauze and applied to the yellow slough, pack gently in the hole and cover with Alleyvn pad for sacral wound daily. The treatment was done from 4/9/17 through 4/13/17 without a indication of what prompted the change. On 4/12/17, the Resident was assessed by the Wound Clinic. The assessment indicated the Resident sacral wound was deeper since last visit The physician changed the treatment of [REDACTED]. be upgraded, limit sitting in chair until a ROHO cushion (pressure relief cushion) for the wheelchair can be obtained and return to the wound clinic in 10 days. Review of the physician's orders [REDACTED]. According to the wound clinic the order did not include bridging the wound to the hip and no treatment was done from 4/13/17 through 4/19/17. There was no documentation why the order included bridging to the hip as there were no areas identified there. The 4/2017 TAR, indicated from 4/19/17 through 4/30/17 the the treatment was completed 3 out of the 5 times to the sacral area and there was no indication the staff requested the Resident's mattress be upgraded and limited the Resident's time in chair or obtained a ROHO cushion through 5/8/17. On 5/8/17, the Resident returned to the wound clinic. The assessment indicated the Resident had been having pain around wound as the VAC dressings was not properly placed. The assessment indicated the area was irritated from the VAC dressing and required debridement. The treatment to the sacral area was changed and the VAC therapy placed on hold and to clean sacral with warm soapy water or normal saline, apply triple antibiotic treatment, moisten gauze and pack wound, cover with Allevyn pad, twice a day. On 5/22/17, the Wound Clinic assessed the sacral wound. On 8/1/17, the Resident was readmitted following a hospitalization and according to the admission orders [REDACTED]. According to the TAR for 8/2017, the staff did not provide care and/or treatment to the sacral pressure ulcer from 8/1/17 through 8/9/17. On 8/9/17, the Resident was seen by the Wound Clinic and although there was no signed physician (telephone) orders for the treatments, the TAR indicated that staff would cleanse the buttock (not sacral) wound with moisten gauze with normal saline and pack area and cover with Allevyn dressing daily. On 10/2/16, a physician's orders [REDACTED]. However, there had been no indication the Resident had an air mattress prior to the order. On 10/5/17 at 12:30 P.M., 10/6/17 at 1:00 P.M., 10/8/17 at 10:30 A.M. and on 10/19/17 at 1:00 P.M., the Resident was observed in bed and the setting were set at 3 , 4 and 7. There was no indication what the correct setting was to be. On 10/12/17 at 8:30 A.M., Unit Manager said that the Resident was followed by the wound clinic. She said the wound clinic took measurements and ordered the changes in treatment. She said that the Facility did not duplicate the wound clinics information and that only weekly skin assessments were done by staff. The Unit Manager said that staff should document the Resident's skin condition during treatment, but could not provide evidence that this was done. In addition, the Unit Manager could not explain all the identified problems with orders, treatments not being followed or obtained and could not show any documentation that the Facility provided treatment to promote healing and prevent a further decline (off loading heels, diabetic foot care, upgraded air mattress). The Unit Manager did not know that the Resident had received antibiotics at the [MEDICAL TREATMENT], until the Survey team contacted the [MEDICAL TREATMENT] center. The center said that they indicated they stayed in contact with the wound clinic for orders. 2. For Resident #5, the facility failed to follow the plan of care to off load the Resident's heels. Resident #5, the facility's plan of care for pressure ulcer was not followed for the use of heel booties to be worn when in bed for off loading the heels. Resident #5 is a long term care Resident with [DIAGNOSES REDACTED]. A review of the last quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated the Resident was totally dependent on staff for activities of daily living, was incontinent of bowel and bladder and at risk of developing a pressure area. The assessment noted the Resident had a Stage 3 pressure area. The medical record indicated the Resident developed this area and the Wound specialist followed the Resident's pressure area and was initially evaluated on 6/1/17 as a deep tissue injury to the left heel of at least 1 day duration. The Wound specialist recommended to use foam booties to off load pressure to the heels. Another consultation report from the Wound Specialist dated 9/14/17, indicated that the heel wound was described as a Stage 3 (pressure wound and to wear foam boots. The plan of care for the pressure area was developed 6/14/17 and listed multiple interventions that included to use heel booties while in bed. The Surveyor observed on 10/9/17 at 7:15 A.M., 10/10/17 at 7:10 A.M., 10/11/17 at 7:00 A.M., 10:40 A.M. and 11:45 A.M., the Resident wore no heel booties. During interview on 10/11/14 at 10:40 A.M., the aide came in to provide care and was asked about the heel booties and said she did not like them. After the Unit Manager said the Resident should have had the booties on as outlined in the plan of care. 3. For Resident #26, the facility failed to prevent an acquired pressure area by not providing adequate incontinent care. The staff nurse failed to inform the facility's Unit Manager who oversaw wound management. Resident #26 was a long term care resident with multiple [DIAGNOSES REDACTED]. A review of the plan of care last revised 6/16/17, for physical functioning indicated the Resident required two staff for lifting and extensive assistance for bed mobility. The plan indicated to inspect the skin with care and for hygiene and bathing was totally dependent on two staff. Another plan of care for being at risk for the development of a pressure ulcer, noted the interventions of turning and repositioning and to provide thorough skin care after incontinent episodes and to apply barrier cream. The two plans had no information for the use of an air mattress which was observed on the Resident's bed during the initial tour on 10/4/17. A review of the nursing documentation dated 9/30/17 at 15:52 (3:52 P.M.) noted a nurse had described a denuded (loss of epidermis caused by exposure to urine, feces, body fluid or friction) area on the buttocks as 5 cm by 3 cm and notified the physician who ordered a treatment of [REDACTED]. A review of the first wound evaluation sheet, completed by the Unit Manager on 10/12/17 (12 days after first seen) and also evaluated with the consultant Wound care specialist noted on the left coccyx area (not the buttocks as noted on 9/30/17 nurses' note) to have a Stage 2 (an injury with partial-thickness loss with exposed dermis) pressure ulcer. Pressure injuries are staged from 1 to 4 to indicate the extent of tissue damage. The coccyx wound was described as being of 1 day duration and measured a length of 5.5 cm by 2 cm width with no depth to the injury and serous drainage. The total surface area was measure at 11 cm. and described as purple/maroon in color. The Wound Specialist recommended a treatment of [REDACTED]. The Surveyor on 10/19/17, was on the Resident's Unit and while walking by this Resident's room at 7:10 A.M. and heard the Resident softly saying I'm cold, I'm cold repeatedly. When the surveyor walked inside the room the Resident was laying crooked in the bed that had an air mattress on with a sheet and blanket on it and could smell urine. Staff entered and exited his/her room to provide breakfast and move the covers but no one corrected the Resident's position. At 8:35 A.M. on 10/19/17, the Surveyor asked the Unit Manager who manages the wound care, to see the wound. When the Unit Manager approached the Resident he/she was still saying, I'm cold, I'm cold and when the bed covers were pulled away the bed linen under the Resident was wet with urine (dark yellow). The cloth incontinent brief, draw blanket, another cloth incontinent brief and then the bottom sheet under the Resident where all wet through, but the disposable incontinent brief near the skin was bone dry. The Unit Manager shook her head and observation of the coccyx wound was a Stage 2 with excoriation surrounding wound. When asked when she had been told of the wound she said on 10/12/17 and had the Wound specialist see it immediately. We reviewed the Resident's poor positioning and multiple layers of wet cloth diapers and sheets under the Resident and said, I don't know what to say this is not how it should be I'll have to talk with the night shift. Additionally, the Surveyor pointed to an area on his/her right inner lower leg that had a maroon color, round shaped skin area that had intact skin, approximately 1.5 inches in diameter. The Unit Manager was not aware of this new area. The air mattress used on the bed was ineffective due to the large multiple layers of wet clothing under the Resident preventing air redistribution under the Resident and not addressed in any plans of care. 4. For Resident #28, the facility failed to provide the dressing cover for a pressure area of the right great toe and was observed to point down as in dropped. Resident #28 was a long term care resident admitted ,[DATE] and had [DIAGNOSES REDACTED]. A review of the last annual Minimum Data Set (MDS) assessment dated [DATE] indicated he/she had a BIMS (Brief Interview for Mental Status) score of 13 out of 15, and had not exhibited any behavioral symptoms. The assessment noted the Resident needed extensive assistance for dressing and bathing and had developed a pressure area. The assessment indicated the Resident had an unstageable area with eschar that measured 2 cm in length by 1.5 cm width. A review of the nursing documentation dated 9/29/17 described the right toe and left ankle as red and swollen and the physician ordered [MEDICATION NAME] (anti-[MEDICAL CONDITION] to treat gout). The physician progress notes [REDACTED]. The nurses' note dated 10/2/17 indicated a call to the Nurse Practitioner due to the right toe area as being open with a necrotic nail bed. On 10/7/17 the right great toe was x-rayed and determined to have [MEDICAL CONDITION] of that toe. The next note dated 10/10/17 indicated the right great toe tip had a black scabbed area and was unstageable. On 10/12/17 the Wound Care Specialist and the facility's Unit Manager evaluated the right great toe and determined he area as a Stage 2 pressure wound that measured 1.5 cm in length and 2.0 cm in width with no depth. The Wound Care Specialist ordered Santyl (an enzymatic [MEDICATION NAME] ointment) ointment applied topically to the area every day and cover with a dry protective dressing. During Surveyor observation with the Unit Manager on 10/19/17 at 9:12 A.M., when the Manager removed the Resident's sock there was no protective dressing over the toe. The Unit Manager said it should had been on. The toe was observed swollen, as a Stage 2 with slough. Interview with the Unit Manager after caring for the she said the area should had been covered to protect the wound and said it may have come off when socks were put on. She said for this wound she was not informed of the area until 10/12/17 and nursing should had reported this area to her when first found on 9/29/17.

Based on record review, observation and resident and staff interviews, the facility failed to ensure a resident who is continent of bladder and bowel receives services and assistance to maintain continence after a change in his/her physical status for 1 Resident (#3), out of 28 sampled residents. Findings include: Resident #3 was admitted in 3/2017 and had [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 7/6/17, indicated the Resident required extensive assistance in his/her transfers, was unable to ambulate and was frequently incontinent of bladder (7 or more episodes of urinary incontinence, and at least one episode of continence). The MDS indicated the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status), indicating the Resident was cognitively intact. Review of the Facility's Incontinence Management/Bladder Function Guideline dated as reviewed on 8/10/16, indicated that the purpose of bladder management was to enable the resident to control urination without catheter, prevent skin problems (such as pressure areas etc), improve morale of the resident, restore dignity and manage urinary incontinence, restore or maintain as much normal bladder function as possible. The policy indicated that upon admission the staff were to complete a Bladder and Bowel Tracking Tool, complete trends or patterns and complete a the Bladder Evaluation Form to determine bladder function. If incontinence is determine staff should be carefully assessed for underlying disorders. Treatment guidelines indicated that staff should work towards retraining bladder function and control the condition through bladder training, techniques, prompt voiding, muscle rehabilitation and medication therapy. Review of the medical record indicated that the staff completed an Admission Bladder Assessment on 3/29/17. The assessment indicated the Resident was continent of his/her bladder functioning. A care plan dated 4/11/17 was initiated and indicated the Resident had some functional incontinence. There was no information to review indicating a change (decline) function following the development of the care plan. The goals included the Resident would maintain my current level of incontinence. The interventions included call bell within reach, evaluate incontinence episodes, monitor and report changes in ability to toilet or continence status. On 7/13/17, the quarterly Bladder Assessment indicated the Resident was currently incontinent of bladder, as evident of wet clothes or incontinence pads. The assessment indicated the Resident would utilize briefs for containment, provide incontinent care and provide assistance to the toilet upon Resident's request. During interview on 10/6/17 ay 12:35 P.M., Resident #3 said that he/she had gone through a lot of medical issues during the past year. The Resident said prior to his/her admission to the facility he/she had a right above knee amputation and since admission a left below knee amputation. The Resident said that initially he/she was not sure if a prosthetic would be beneficial. Resident #3 said that he/she had been trained to stand and pivot for transfers to toilet, chair, etc, but since the second amputation he/she can no longer stand and pivot. The Resident said that he/she was receiving services to transfer by a sliding board, but this was not going to be enough to ensure independence. The Resident said with the loss of his/her second lower leg he/she could no longer transfer to the commode and toilet. The Resident said the commode was removed from his/her room and the bathroom did not accommodate a transfer (as currently using a slide board). Resident #3 said that the staff put an adult brief on him/her and was expected to go in the brief. The Resident said that this was not what he/she wanted to do and had asked for a commode. The Resident said a commode with removal arms would accommodate his/her ability to transfer. The Resident said that he/she knew when he/she had to void, but had to go in the brief. Observation of the Resident's bathroom had a commode chair over the toilet, but did not have enough space on the 2 sides for the Resident to safely use the slide board onto the toilet. In addition, no commode was observed in the Resident's room. Interview with the Director of Rehabilitation on 10/12/17 at 12:00 P.M., she said the Resident had received occupational services from 8/2/17 - 9/28/17. The Director said Resident #3's services included goals to promote his/her ability to transfer using a slide board as part of skilled services, with a focus on upper body strengthening to improve functional status with self care and transfers. The Director said she did not know why the Facility staff were not continuing with the slide board transfers to a commode. She said that according to the treatment documentation, at the time of discharge on 9/28/17, the Resident required minimal assistance for commode transfers and had a bariatric commode (due to the seat being wider and rubber and more conducive to a slide board transfer). The Director said that she did not know the Resident was wearing incontinence briefs. Interview with the Director of Nurses (DON) on 10/19/17 at 10:15 A.M., the DON was informed that the Resident said that after losing his/her second lower limb that he/she was made to wear briefs rather than maintain his/her normal bladder continence by being assisted with toileting. The DON offered no other information or documentation.

Based on observation, interviews and record review the Facility staff failed to ensure that appropriate, individual and meaningful care and services were provided to meet the highest level of mental and psychosocial functioning for 2 Residents (#1 and #6), from a total sample of 28 residents. Findings included: 1.) Resident #1 was admitted in 11/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE], the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status), indicating no cognitive loss and capable of making his/her decisions. The MDS indicated the Resident did not exhibit depression, but had some infrequent symptoms that included feeling tired and had exhibited verbal outbursts. The MDS indicated the Resident required minimum assistance's in his/her activities of daily living. Resident #1 asked to speak with the Surveyor on 10/8/17 at 11:15 A.M. Additional discussion were held with Resident #1 on 10/8/17 at 11:50 A.M., 12:40 P.M. and 1:45 P.M. and on 10/10/17 at 11:00 A.M., 10/11/17 at 10:00 A.M. and 4:00 P.M. and on 10/19/17 at 11:00 A.M. Resident #1 said that she had move to the Facility from out of state to be closer to his/her family. Resident #1 said he/she had hoped to transition from the nursing home to an Assisted Living, but had multiple medical hospital admissions and had required surgery for [REDACTED]. The Resident said that he/she still plans to leave but had remained in the Facility because all the medical complications [REDACTED]. The Resident said that he/she initially had been hopeful about the move, but shortly after admission he/she witnessed several and experienced a number of situations that increased his/her anxiety and had made him/her feel trapped, hopeless and depressed. The Resident said that the staff were miserable, mean, rude and had made everything he/she did an issue. The Resident said the staff did not listen to him/her and he/she got so frustrated he/she acted out. Resident #1 said that he/she swore at staff and had smoked in the bathroom to calm him/herself down, but things got worse. The Resident said Staff started accusing him/her of smoking in the bathroom when he/she had not, not following the rules and had been accused of drug seeking (pain medications). The Resident said when he/she told the staff he/she did not feel well and needed to go to the hospital, Nurse #2 told the staff to tell the Resident to call 911 him/herself (if wanted to go). The Resident said he/she had no confidence in the staff, felt trapped and that his/her complaints only caused more trouble (for him/her). Resident #1 said that he/she has had a long history of [MEDICAL CONDITION], anxiety and depression associated with [MEDICAL CONDITION]. The Resident said that he/she had experienced several traumas and that he/she had successfully been treated with medication and 1 to 1 psychotherapy. Resident #1 said that he/she had always been able to structure his/her life and used notes for reminders to make sure he/she did not forget things. Review of the discharge summary dated 11/8/16 indicated the Resident moved from out of state and had been treated in the past for [MEDICAL CONDITION], long standing history of depression, anxiety, [MEDICAL CONDITION] and symptoms of personality disorder. The discharge record indicated the Resident's treatment included psychoactive medications, 1 to 1 psychotherapy and to ensure to incorporate non-pharmacological intervention including fresh air sunshine and short walks. The discharge summary identifies Resident triggers which include fears of some memory deficits (and therefore, writes notes to self), is alert and oriented but becomes agitated with prolonged direct questioning. Review of the Resident's care plans identified several plans to address the Resident's psychosocial problems. - Resident has [MEDICAL CONDITION] and gets anxious and nervous in new surroundings. The care plan was initiated on 11/15/16 and last revised on 3/2/17. The goal was to ensure the Resident would have someone to talk to when feeling anxious. The interventions included medication, maintaining that the Resident's stuff was not disturbed and allowing the Resident the choice to make decisions (even if decision is not what is asked of him/her). - Sad and withdrawn with [DIAGNOSES REDACTED]. The goal was the Resident would focus on future, verbalize feelings of control in his/her life and talk about positive and happy memories. The interventions included medication, encourage activity involvement, help keep in contact with family, introduce to other residents, offer foods that he/she likes, take time to discuss feelings when feeling sad and inform physician if symptoms not improving. - [MEDICAL CONDITION] was identified as it has a potential for sleep deprivation. The care plan identified that no sleep could cause related behavioral symptoms and was initiated on 11/25/16 and last updated on 12/3/16. Goals and interventions include no symptoms of sleep deprivation and administer sleeping medications, establish routine, discourage activities that may keep awake and maintain a conducive environment for sleep. -And, on 6/15/17 a care plan was initiated that indicated the Resident had behaviors that included smoking in room, not taking medications (hiding in room) and non compliant with diet orders. The goal was for the Resident to stop behaviors with staff intervention. The interventions included medications, notify the physician if behaviors interfere with daily living, cigarettes kept in the medication room, notify the social worker of any changes, tell the Resident what your going to do and refer to psychiatric services as needed. During interviews, Resident #1 shared the following information and following the initial interview on 10/8/17 and during numerous additional meeting, the information was shared with the Facility staff (including the Administrator, Director of Nurses, Social Worker, Corporate Regional Nurse and Corporate Administrator). - Resident #1 said Nurse #2 was miserable and should not work here. The Resident said Nurse #2 works a lot because of staffing problems and is in everyone's business. The Resident gave the following examples: - Due to [MEDICAL CONDITION], the Resident is up at night, the kitchen is behind the nurse's station and Resident will (often ) get up during night ask for staff and sit in a chair on the wall facing the nurse's station. Resident #1 said Nurse #2 and other staff yells at him/her for getting a snack (ice cream) because he/she a diabetic and tells Resident cannot sit viewing the nurses station. Resident #1 said Nurse #2 remove the chair to prevent the Resident from sitting. The Resident said it is very confrontational. The Resident said I have [MEDICAL CONDITION] and ice cream is not that bad for me. The Resident said they holler at me and other Residents and Family's. They do not want others to see them not working or answering call lights. Record review indicated the Resident has [DIAGNOSES REDACTED]. The assessment indicated resident choice and encourage adequate intake. Further review indicated that the nursing staff documented the Resident's [MEDICAL CONDITION] and request for ice cream or peanut butter toast as a behavior. A sample of nurses' notes that identified the Resident asking for ice cream (or peanut butter toast) or sitting at nurse's station at night as a behavior included the following dates; 1/2/17, 1/5/17, 1/30/17, 2/19/17, 2/23/17, 4/ 18/17, 4/19/17, 4/23/17, 4/30/17, 6/25/17, 6/26/17, 6/27/17, 6/28/17, 9/1/17 and 9/16/17 (when the nurse told Resident not to eat ice cream, the Resident became angry and yelled at the Nurse. The Nurse wrote she redirected the Resident to his/her room and if the Resident had a problem we could go to the administrators office . the nurse wrote the resident walked away. - Resident #1 said that they staff do not pay attention to Resident's who die. The Resident said that shortly after being admitted to the Facility the Resident heard staff talking about a Resident that they had found on the floor. The Resident said the staff were heard laughing and said I wonder how long she has been lying there dead. The Resident said he/she was frightened by their statement, but had gotten up out of bed due to the commotion and saw a Resident on the the floor and staff standing around the Resident. In addition, the Resident said that a friend he/she had met at the Facility was dying and that he/she had asked for him/her to visit, The Resident said that when he/she tried to sit with the Resident, Nurse #2 told the Resident he/she could not and that Resident #2 should not involve self with other Residents. The Resident said although he/she had visitors, there were times the Resident was alone and it was a friend. (The Resident that Resident #1 identified did pass a away at Facility). Resident's #1 record did not contain information about the incident, but Family and a Non-Sampled Resident (who asked to not be identified) supported the statement. -The Resident said that he/she did not feel safe in the Facility and that on a number of occasions he/she had to call an ambulance. - The Resident said that the staff have accused him/her of number of things which includes smoking in the bathroom, drug seeking (pain medication) and refusing to take his/her blood pressure. The Resident said maybe 2 weeks ago Nurse #2 told the Resident's nurse if the Resident wanted to go to the hospital to tell the Resident to call the ambulance him/her self. - Resident #1 said he/she saw 2 staff dragging a Resident by arms and feet dragging down the hall. - Call bells not being answered and was afraid that if something happen to him/her no one would come. - The Resident said that in May of 2017, he/she was on precautions for an infection in his/her sputum. The Resident said he/she was placed on droplet precautions, wore a mask and was told to not leave his/her room. The Resident said that he/she kept in quarantine and it was awful. Resident #1 said staff constantly yelled at him/her if left the room (even if wearing mask). The Resident said that it was discouraging and that during this time he/she had forgotten to give his/her cigarettes to the staff. The Resident said that he/she had smoked in his/her bathroom once in the past, admitted it and knew not to do it again, however staff refused to believe him/her and sent him/her to the hospital for psychiatric care. The Resident said it was awful and that he/she behaved awful because of their treatment towards him/her and them not believing him/her. The Resident said even the Facility's psychiatric consultant would not listen to him/her and made him/her feel trapped and hopeless. - And, the Resident said the Facility has deemed that he/she is medication seeking pain pills. The Resident said this was humiliating and that every time he/she asks for pills staff indicate that he/she is not telling the truth. Record review indicated that the Resident had 12 hospitalization s since 1/15/17. During review all transports either ended up in an admission or the Resident was kept for observation. On 5/19/17, 7/25/17, 7/29/17, 9/30/17, 7/29/17,10/1/17, 9/1/17, there was documentation the Resident asked to go to the hospital after having reported changes in condition prior to the transfer. The medical record indicated the Resident had chronic pain that included [MEDICAL CONDITION], spinal stenosis, torn rotator cuff (that was surgical repaired times 2), fractured ribs and foot from falls. The Resident was followed by a surgeon and the pain clinic and was administered steroid injections. The nurses notes noted the Resident's requests for pain medication and included observations that the Resident was walking fine, not distressed, was asking before they could administer and was med seeking. Record review indicated the Resident admitted to smoking in the bathroom on 3/25/17. The Resident said that he/she was stressed and agreed not to do it again. On 5/23/17, the Resident was readmitted [MEDICAL CONDITION] in sputum and placed on droplet precautions. The nurse's notes indicated that the Resident was noncompliant with the precautions and was coming out of room. The Resident was encouraged to not smoke but chose to smoke (in the designated area), but from notes was restricted from doing so on 5/24/17. The Resident was assessed by the psychiatric consultant (5/25/17) and had indicated the Resident should be hospitalized for [REDACTED]. On 6/14/17, the Resident was taken off precautions. On 6/16/17, the psychiatrist assessed the Resident because of becoming angry by what the Resident states are false accusations by the staff. The psychiatrist does not indicate if he asked the Resident what he/she had been accused of but should be evaluated at the hospital. On 6/26/17, the nurse's notes indicated the Resident had a lighter. The Resident said that he/she had gone out with family and had forgotten to give the lighter back to facility when returned. The note indicated a room search located a pack of cigarette. The Resident gave the cigarettes to the staff and denied that he/she had smoked in the facility. Psychiatric services assessed the Resident on 6/27/17 and ordered the Resident be sent to the hospital via a section 12 for inpatient hospitalization . The Resident was transported and returned with the emergency room indicating that psychiatric inpatient care was not for a behavior of having a lighter and cigarettes. The psychiatric consultant assessed the Resident on 6/2/9/17. The note indicated the Resident as neglectful for safety and had poor judgement. The psychiatric consultant requested further testing and that in the future if the Resident violated smoking policy to call the police. An additional psychiatric evaluations was attempted on 7/2/17, but Resident refused. The note indicated the Resident was able to give basic information, but when found out the consultant psychiatrist ordered the assessment the Resident refused and said I don't want anything to do with . his orders. On 10/8/17 at 11:15 A.M., the Surveyor reported to the Administrator that the Resident felt hopeless and was fearful of staff. On 10/10/17 at 8:00 A.M. the Administrator said that Social Worker #1 (SW #1) had met with the Resident on 10/9/17 and that the Resident felt supported and safe. He said he spoke with Nurse #2 and she had no idea what the Resident was talking about. The Administrator said Nurse #2 can come across loud and intimidating to some. During interview with SW #1 on 10/10/17 at 8:45 A.M., she said she met with the Resident and the Resident shared the information about his/her feelings of anxiety and hopelessness. She said that she had not been active in the Resident's care as she had just increased his/her hours at the Facility. SW #1 did not know the Resident's actual history ([MEDICAL CONDITION] and potential problems associated with his/her anxiety and depression) but planned on following up to ensure the Resident felt safe and cared for. The SW said that she had heard that the Nurse had attempted to send Resident #1 on a Section 12 for having cigarettes in room. SW #1 said that it was concerning. The Resident was not moved off the unit until 1012/17 and on 10/13/17, observations indicated the Resident's belongings were left on the floor unpacked in suitcases. The Resident said due to limited shoulder range he/she could not reached down to unpack them. On 10/11/17 at 4:00 P.M., Resident #1 and his/her Family met with the Surveyor. The Family supported the allegations made by the Resident and said that he/she was also had concerns about the Resident's care. The Family said the staff were intimidating. The Family said they had reported their concerns to the Facility and outside agencies, but had felt it had made it worse. The Family said that the staff did not listen to the Resident care needs and have told the Resident to call 911 if he/she felt needed to go to the hospital. The Resident and Family were agreeable to meet with the Facility Staff. The SW, Administrator and Director of Nurses (DON) was asked to meet with the Resident and Family. Following the meeting with the Family and Facility Staff, the Surveyor asked for an update. On 10/19/17 at 11:30 A.M., it was determined that the meeting with the Family and Resident's voiced issues had not been addressed. The Administrator had not taken down any notes and the DON did not attend. The SW had notes but had not followed up with any additional information and there was no change to the Resident plan of care to ensure the Resident felt safe and was receiving services that promote and address her depression and anxiety. The Resident was interviewed and said that other than the room change no one from the no staff had asked met with him/her about addressing his/her needs to ensure he/she feels safe and does not feel hopeless, fearful or trapped. 2.) For Resident #6 the Facility failed to ensure that a physician prescribed antipsychotic medication was available and administered for 22 days, resulting in significant medication withdrawal symptoms to the Resident. Findings include: Resident #6 was admitted to the Facility in 11/2012 with the following pertinent Diagnoses: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicates the following: Resident #6 is cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 4 out of 15, requires total assist with activities of daily living and requires 1 assist for ambulation with walker. Review of Care Plan for Alteration in elimination of bowel/bladder function (initiated 5/25/17) indicates: bowel medication as ordered and monitor use and effectiveness, encourage fluids, foods high in fiber, and monitor bowel status frequency. Review of the physician's orders [REDACTED]. by mouth two times per day (start date of 1/2017 for [MEDICAL CONDITION] and anxiety disorder). Review of the MAR for 5/2017 indicates that from 5/22/17 through 5/29/17 (7 days), Resident #6 did not receive his/her prescribed [MEDICATION NAME] (14 doses indicate H for held), however the Nursing Progress Notes contradicts the MAR and indicate that the Resident did not receive the medication for 20 days or 40 doses (5/17/17-6/5/17). The Facility's MAR is an electronic system. Review of the Nursing Progress Notes from 5/17/17 (5 days prior to the MAR documentation of 5/22/17) to 6/5/17 indicates the following: - 5/17/17: medication unavailable, MD working on insurance override at present time and nothing in kit upstairs. Waiting for MD to work on insurance paperwork. - 6/2/17: the Psychologist was asked to see the Resident. The Psychologist said that the DON is working on getting the medication, so if it is approved, continue with it, if not, give [MEDICATION NAME] 200mg. at bedtime. (per MAR [MEDICATION NAME] never received) -6/3/17: [MEDICATION NAME] on hold -6/4/17: Medication on hold - 6/5/17: [MEDICATION NAME] was delivered just now at 11:45 P.M. Review of the Medical Psychotherapy Follow-up Visit notes indicate the following changes to the Resident's mood and anxiety level: - 5/30/17: (3 days after not receiving prescribed [MEDICATION NAME]) Reason for follow-up: change in mood evidenced by: feeling hopeless Resident said I'm at the end of my rope. This is the worst place I've ever been in. - 6/7/17: (2 days after [MEDICATION NAME] re-started) presenting problem: increased anxiety due to change in medication [MEDICATION NAME] evidenced by anguished facial expressions refers to discussion with nursing staff that unavailable medication may be contributing to Resident's feelings of increased anxiety, anguish and fearful stress and staff is still waiting for the improvement in mood. Recommendations: 1:1 therapy to support the Resident who feels out of control Nursing Progress Notes indicate the following Resident mood changes (while medication unavailable and not administered): - 5/21/17: Resident approached staff and said that he/she heard someone was coming here to shoot everyone (auditory hallucinations). - 5/29/17: general discomfort and confused, putting fingers in ears and saying he/she was on telephone. - 6/2/17: significant change as of 5/23/17 due to a decline in medical condition that is causing an unsteady gait -Recreation Therapist. On 10/6/17 at 2:30 P.M. the Surveyor interviewed the Psychologist with the survey team. The Surveyor told the Psychologist that his notes were not legible. he said I get that a lot. The Psychologist said that the Resident did not receive his/her [MEDICATION NAME] because of an insurance issue and that he would have thought that the Facility would have taken care of it, but didn't. The Psychologist said that he was unaware of a change /decline in physical condition (gait disturbance), but that it could be a side effect of the anti-psychotic medication. The Psychologist said that the primary care physician was also aware of the medication not being available for administration.

Based on record review, observation and interview, the facility failed to administer a prescribed medication in accordance with the physician orders, as they were left at the bedside and the Resident not able to self administer the medications. Findings include: Resident #4 was admitted to the Facility in 5/2015 and was legally blind. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 7/25/17 indicated the BIMS (Brief Interview for Mental Status) indicated Resident #4 scored a 13 out of 15, indicating the Resident was cognitively intact. The MDS indicated the Resident had vision loss and required extensive assistance in his/her ADLs (Activities of Daily Living). During observations on 10/13/17 from 8:45 A.M. through 9:30 A.M., 2 medications ([MEDICATION NAME] solution 0.1% ([MEDICATION NAME] used to treat allergic [MEDICAL CONDITION] and symptoms of itchy, red swollen and watery eyes), instill 1 drop in each eye, twice daily and Artificial Tears solution (artificial tear and lubricant), instill 2 drops in each eye, four times daily), were observed on the Resident's tray table in his/her room. Record review indicated that there was not a physician's orders [REDACTED]. The record indicated that the responsibility of drug administration was deferred to the licensed staff of the facility for these medications. On 10/13/17 at 9:30 A.M., the Resident's medication Nurse #5 was asked about the medications left on the over bed table. She initially admitted that she had left the medication at the bed side, but later retracted her statement on 10/13/17 at 11:30 A.M. During interview with Resident #4 on 10/13/17 at 11:50 A.M., the Resident was asked about the prescribed eye medications. Resident #4 said that it would not be safe for him/her to self administer eye drops because of his/her poor vision and dexterity. Resident #4 said that the morning the Nurse had asked him/her if he/she was able to administer the eye medication. Resident #4 told the nurse he/she could not. On 10/13/17 at 10:30 A.M., the Director of Nurses was asked if she had been made aware of the medication left at the bedside by Nurse #5 The Director said that Nurse #5 told her that she had not left the medications at the bedside. The Director said that the Nurse was nervous and that was why she had admitted to leaving the medications.

Based on records reviewed and interviews, for 2 of 3 sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that all alleged violations involving abuse, neglect or mistreatment were immediately reported to the Supervisor, Executive Director or Director of Nurses, were thoroughly investigated and were reported within two hours to the Department of Public Health. CNA #1 said she witnessed CNA #2 tell Resident #1 and Resident #2 to shut up or shut the [***] up on two occasions during September 2016. CNA #1 did not immediately report the alleged incident to the Administrator, an immediate internal investigation was not initiated in accordance with the Facility Abuse Policy, CNA #2 was not suspended in accordance with the Facility Abuse Policy and the allegations were not reported to the Department of Public Health for 17 days. Findings include: The Facility's Policy and Procedure on Reporting and Investigation of Alleged Violations Involving Abuse, dated 9/7/16, indicated it is the policy of the Company to take appropriate steps to prevent the occurrence of abuse and the responsibility of each employee to immediately report all allegations of abuse to the supervisor, Executive Director or Director of Nurses. Immediately is defined as soon as possible but not to exceed 24 hours. The Facility Policy indicated that the Facility takes appropriate steps to prevent the occurrence of abuse which includes using disparaging and derogatory terms to residents. Resident #1's Minimum Data Set (MDS) Assessment Form, completed 07/14/16, indicated Resident #1 had a [DIAGNOSES REDACTED]. The Surveyor was unable to interview Resident #1 due to Resident #1's impaired cognition. Resident #2's MDS Assessment Form, completed 06/11/16, indicated Resident #2 had a [DIAGNOSES REDACTED]. The Surveyor was unable to interview Resident #2 due to Resident #2's impaired cognition. A Department of Public Health Incident Report Form, dated 09/27/16, indicated that on 09/10/16, CNA #1 witnessed CNA #2 yell - Shut up- at Resident #1 and on 09/16/16, CNA #1 witnessed CNA #2 yell at Resident #2 - Shut the [***] up- and kept yelling at Resident #2. Although CNA #1 said she could not specify the date of the alleged incidents, employee punch detail forms for CNA #2 indicated she punched into the Facility at 2:48 P.M. and punched out at 9:03 P.M. on 9/10/16, into the Facility at 4:38 P.M. and punched out at 11:03 P.M. on 9/16/16 and punched into the Facility at 3:01 P.M. and punched out at 10:59 P.M. on 9/17/16. The Surveyor interviewed the interim Director of Nurses and interim Executive Director at 5:20 P.M. on 3/6/17. The interim Director of Nurses and interim Executive Director said although it was the Facility policy for all staff to immediately report all allegations of abuse, CNA #1 did not immediately report the alleged incidents and, as a result, the Facility failed to immediately report the two allegations of verbal abuse to the Department of Public Health and failed to initiate an investigation for 17 days. Although the first incident was witnessed on 9/10/16, CNA #2 was not suspended until 9/19/16. Despite the Facility policy which indicated staff members accused of abuse should be suspended, CNA #2 continued to work for a period of 9 days and was in direct contact with Resident's, placing them at risk for possible verbal / physical abuse.

Based on record review, interview and observation, the Facility failed to ensure for 2 out of a total sample of 24 residents (#5 and #11) that assessment of pressure sores was implemented. Resident #5 developed osteo[DIAGNOSES REDACTED] in a Facility acquired pressure sore. Findings include: 1. Resident #5 was admitted to the Facility in 8/2015, and his/her [DIAGNOSES REDACTED]. Review of the Wound clinic notes, dated 11/18/15 and 1/6/16, indicated that Resident #5 had 2 pressure sores upon admission to the Facility, one stage 4 pressure sore (full thickness loss with exposed bone, tendon and muscle) to the coccyx (A) and one stage 3 (full thickness loss without exposed bone or tendon and may have slough) to the right ischium (B). The Surveyor requested the weekly skin assessments for Resident #5's pressure sores since his/her admission. The Interim Director of Nurses (DON) was unable to provide any evidence that Resident #5's pressure sores were assessed until 3/2016, although the staff provided treatments to the pressure sores. Review of the skin assessments provided indicated the documentation was incomplete, and did not identify the stage of the wounds, any drainage or interventions, and the name of the nurse who documented the findings. Review of the Facility skin integrity guideline, (no date) indicated that evaluation and observation is to be completed within the first 24 hours of admission/quarterly/significant change of condition using the weekly skin review. The skin integrity guideline indicated that care of a pressure sore included weekly documentation that is accurate and thoroughly completed for each wound and the DON or designee observed the wounds on a weekly basis. The skin integrity guideline indicated that each facility must create a manual tracking system to monitor completion of the weekly skin evaluation. In addition nutritional assessment determines need for nutritional interventions. Review of the nurse's note, dated 1/12/16, indicated that Resident #5 developed a new pressure area, a superficial area to the left buttocks (C) that measured 1.3 centimeters (cm) by 1.2 cm. The nurses' notes, dated 2/4/16, 2/11/6, 2/22/16, 3/2/16, and 3/16/16 identified different staff nurses assessed Resident #5's pressure sores but no staff nurse identified the actual stage of the pressure sores. Review of the Wound clinic notes, dated 2/17/16, indicated that Resident #5 had a new left buttock pressure sore (C), stage 3 that measured 1.2 cm by 1 cm by 0.5 cm. with moderate serosanguinous drainage. There was no weekly skin assessment provided to the Surveyor for Resident #5's left buttock pressure sore (C) until the 3/16/16 assessment. The 3/16/16 to 7/12/16 assessments were incomplete, did not identify any stages and drainage until 7/12/16, until the left buttock/ischium pressure sore was now a stage 4 pressure sore with moderate drainage. Review of the nurse's note dated 5/25/16, indicated new pressures sores had developed. Review of the weekly skin assessment, dated 6/1/16 indicated Resident #5's left buttock wound (C) was now 3.5 cm by 3.5 cm by 0.5 cm, and there was no documentation that the wound had worsened and was larger than before Review of the Wound Clinic note, dated 6/3/16, indicated that Resident #5's left buttock pressure sore (C) was deteriorating, measured 4.0 cm by 3.2 cm by 0.9 cm and had moderate yellow drainage. Review of the Wound Clinic note, dated 6/17/16, indicated that the left buttock pressure sore (C) had worsened, the pressure ulcer had a strong odor and the left lateral leg (D) had worsened. The Wound Clinic note indicated that a protein supplement was needed for wound healing. There was no indication through the nurse's notes that the Physician was notified of the worsening wounds. Review of the Wound Clinic notes, dated 7/8/16, indicated that Resident #5 now presented as having possible osteo[DIAGNOSES REDACTED]. The Surveyor observed the ADON on 7/18/16 when he provided wound care. The Surveyor observed that Resident #5 dressings were saturated with bloody drainage and the old dressings had a strong odor from the drainage. The Surveyor observed Resident #5 on a low air loss mattress but staff were unable to identify when the mattress was initiated, whether the settings were correct and the type of pressure relieving mattress. The Surveyor interviewed the Physician on 7/19/16, at 11:30 A.M. The Physician said that he received a recent telephone call from the Wound Clinic Physician within the last week, regarding Resident #5's deteriorating pressure sores. The Physician said that the Wound Clinic Physician was worried that Resident #5 had osteo[DIAGNOSES REDACTED]. The Physician said that is how he found out about the deteriorating wounds. The Physician said he ordered an MRI (magnetic resonance imaging) and results were pending regarding the next course of treatment for [REDACTED]. Review of the MRI results faxed to the Surveyor on 7/25/16, indicated that Resident #5 had bone marrow [MEDICAL CONDITION] involving the left ischium extending to the base of the left ischial spine, consistent with left ischial osteo[DIAGNOSES REDACTED]. 2. For Resident #11, the Facility failed to identify and assess his/her pressure sore upon admission to the Facility. Resident #11 was admitted to the Facility in 7/2016 and his/her [DIAGNOSES REDACTED]. Review of the initial nursing assessment, dated 7/12/16, indicated that Resident #11 had two open areas of skin breakdown on his/her coccyx and lower left leg. The initial assessment indicated that if a skin condition was present, the nursing staff was to initiate a weekly skin report. Review of the admission nursing note, dated 7/12/16, indicated Resident #11 had an open area on his/her coccyx, 1 inch by 1 inch and an open area on the left gluteal fold 3 cm by 2 cm. The Surveyor requested the initial weekly skin assessment from Unit Manager #1 on 7/20/16. Unit Manager #1 said she was unaware that Resident #11 had any open areas on his/her coccyx and gluteal area so weekly skin assessments were not completed.

Based on staff interview and the record review of 1 (#15) of 24 sampled residents, the facility failed to provide Resident #15 with an adequate transition plan prior to the resident's move to another unit. Findings include: Resident #15 was a long term resident at the facility with [DIAGNOSES REDACTED]. Review of the annual and quarterly assessments from 12/6/11 through 11/29/12 indicated that Resident #15 had cognitive and short and long term memory deficits and required extensive staff assistance due to an unsteady gait. The quarterly assessment, dated 2/28/13, indicated that the resident was dependent on staff, had an unsteady gait and was limited to a wheelchair for mobility. Record review on 3/28/13 indicated that Resident #15's health care proxy received a notice on 7/18/12 that Resident #15 was moving to Room 15 B on the A unit on that day. A social service note, dated 7/21/12, indicated that Resident #15 was "very weepy today, asking what (the resident) did wrong to be taken out of his/her home". The note continued to describe the resident as sobbing during lunch and asking to be brought back to his/her home. The note further described that the resident was taken to the ACU for a visit, where the resident's mood improved and the resident stated that he/she was never leaving again. When the resident was assisted back to the A unit, the resident began crying again and kept repeating, "What did I do wrong?" A social service note, dated 8/29/12, indicated that the resident was adjusting to the A unit. A social service note, dated 9/19/12, indicated that the social worker contacted the resident's health care proxy to follow up on a meeting that had taken place on 9/17/12 and to inform the health care proxy that Resident #15 would begin going to the ACU for a couple of hours a day as well as participating in activities on A unit. A social service note, dated 10/27/12, indicated that the social worker spoke to the resident's health care proxy regarding the proxy's wishes to no longer have Resident #15 attend programs on the ACU. The health care proxy stated that family had noticed a decreased mood upon the resident's return from the ACU and felt that it would be in the resident's best interest to remain on the A unit for activities. On 3/27/13 at 11 A.M., the surveyor met with the ombudsman. The ombudsman stated that Resident #15 was moved off the ACU to the A unit without any prior notification to the family. The ombudsman stated that the family was told the resident needed to be moved off the ACU because the resident was now dependent on a wheelchair for mobility which posed a safety risk to the other residents on the unit. On 3/28/13 at 2:30 P.M., the surveyor met with the social worker. The social worker stated that the clinical team felt that the resident needed to be moved off the unit due to the resident's dependence on a wheelchair that would pose a safety risk to the other residents on the unit. The social worker indicated that the admission/discharge criteria for the ACU indicated that residents were not appropriate for the unit if they were dependent on a wheelchair for mobility. The social worker indicated that the resident had used the wheelchair from time to time while on the ACU, but was now dependent on it completely. The social worker stated that she believed that she had left a message with the health care proxy prior to the transfer, but could not recall if the health care proxy returned that call. The social worker stated that a bed was available on the A unit and so the resident was moved to take advantage of that vacancy. The social worker stated that no transition plan took place prior to the resident's transfer off the unit. On 3/29/13 at 9:30 A.M., the surveyor met with the Administrator and the social worker. The Administrator shared the criteria for the now called "Alzheimer Friendly Unit" which indicated "the resident must be ambulatory or use assisted devices such as walkers or canes. Geri-chairs and/or wheelchairs are not appropriate for the unit". The Administrator stated that Resident #15 was moved quickly due to the bed availability on the A unit. The social worker indicated that a phone call had been made to the health care proxy with no return response. Both the Administrator and the social worker indicated that no transition meeting took place with the health care proxy prior to the move. They also indicated that the team was aware of the resident's mobility status and the possibility of a move off the unit, but the availability of the bed on the A unit impacted their decision to move quickly. The Administrator and social worker explained that a transition plan to ease the resident's difficulty in transition was developed and implemented with the health care proxy's approval after the move. They also indicated that the health care proxy decided to stop the visits to the ACU because the team and the resident's health care proxy determined that the resident was no longer benefiting from the visits. Observations during the survey indicated that Resident #15 had adjusted to the A unit at this time. Nevertheless, the facility failed to develop and implement a transition plan for Resident #15, prior to the move on 7/18/12, in an effort to minimize potential distress to the resident and to develop a strategy to ease the resident's depressed feelings at the time of the transfer.

Based on record review, observation and staff interview, the facility failed for 1 resident (#9) of 24 sampled residents to provide sufficient amounts of fluids, based on the individual needs of the resident to prevent dehydration. For Resident #9, with a history of dehydration, the facility failed to utilize the assessed fluid needs to ensure that the resident was receiving a sufficient amount of fluid. When the resident developed a urinary tract infection and had persistent fevers, the facility failed to assess the resident's fluid needs and institute interventions. The resident became dehydrated. Findings include: Resident #9 had [DIAGNOSES REDACTED]. According to the 11/9/11 quarterly minimum data set (MDS) assessment, the resident was cognitively impaired and was dependent on staff for all activities of daily living including eating and drinking. The resident was coded as incontinent of bowel and bladder. The resident's height/weight was reported as 67 inches and 123 pounds. Review of the Nutritional Screening and Assessment completed by the dietician on 1/31/11 revealed that the resident's estimated fluid intake should be between 1600 - 1800 cc (cubic centimeters) per 24 hour period. This figure represents the amount of fluid intake the resident should receive in order to prevent dehydration. The amount of fluid intake needed by the resident would fluctuate if the resident's condition fluctuated. For example, increased fluid may be needed if the resident had a fever. Per record review, on 11/28/11 the physician reported that the resident had a temperature of 103 degrees, was lethargic for 2 days and had decreased oral intake. The physician reported that the resident was dehydrated with a sodium level of 153 (range 133-145); and a blood urea nitrogen level (BUN) of 32 (range 10 - 24). The physician ordered antibiotics to treat a urinary tract infection and initiated intravenous (IV) hydration to correct the resident's dehydration. Review of an 11/28/11 care plan for "elevated sodium and BUN levels" listed as interventions "PO (oral) plus IV fluids." The care plan did not quantify the amount of intake that the resident should receive in order to ensure sufficient fluid intake. Intake and Output (I & O) was to be monitored. On 12/9/11, the 3-11 nurses reported that the resident's antibiotics had concluded with a good appetite and "fluids taken well." Review of I & O summary sheets from 12/13/11 through 12/17/11 are listed below: 12/13/11: Intake/1300 cc's Output/incontinent x 8 12/14/11: Intake/1350 cc's Output/incontinent x 6 12/15/11: Intake/690 cc's Output/incontinent x 4 12/16/11: Intake/1140 cc's Output/incontinent x 6 12/17/11: Intake/1420 cc's Output/incontinent x 7 Based on the above information, the resident's average fluid intake for the 5 days period was approximately 1180 cc's. The 1180 cc fluid intake indicated that the resident's intake fell below the resident's recommended daily fluid intake range of 1600 - 1800 cc's in order to maintain proper hydration and health. Further review of I & O summary sheets reflected a change in the resident's fluid intake status beginning 12/25/11. However, there were no documented nurses' progress notes from 12/25/11 through 12/30/11 that explained this change in status. Review of I & O sheets from 12/25/11 through 12/29/11 are listed below: 12/25/11: Intake/780 cc's Output/incontinent x 6 12/26/11: Intake/1180 cc' s' Output/incontinent x 6 12/27/11: Intake/570 cc's Output/incontinent x 4 12/28/11: Intake/970 cc' s' Output/incontinent x 7 12/29/11: Intake/510 cc' s' Output/incontinent x 2 Based on the above information, the resident's average fluid intake for the 5 day period was approximately 800 cc's. The approximately 800 cc's indicated that the resident was receiving less than half of the recommended 1600 to 1800 cc daily fluid intake, placing the resident at risk for dehydration and/or other health issues. On 12/31/11, the 7-3 nurse reported that the physician was contacted because the resident had developed an elevated temperature of 100.4. The physician ordered to obtain a urinalysis and urine culture, and then start the resident on antibiotics. I & O review recorded the intake on 12/31/11 as 1500 cc's and output as incontinent x 6. According to the Nurses Notes, beginning on 1/1/12 and continuing through 1/3/12, the resident had a persistent elevated temperature(s) while on antibiotics. The resident was kept on bed rest due to sleepiness and lethargy, had a poor appetite, and was reported to be moaning. There was no documented evidence that nursing staff assessed the resident's skin, mucous membranes or skin turgor for signs of dehydration. According to the 1/2/12 I & O sheets, the resident's 24 hour total intake was only 690 cc's and output as incontinent x 7. No I & O was available for review for 1/3/12. The only documented intake was via the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 2:00 P.M., 6:00 P.M. and 10:00 P.M, the resident took 120 cc's of dietary supplements each time without quantifying the amount the resident had actually consumed. Nurse #2 was interviewed on 1/4/12 at 2:15 P.M.. Nurse #2 reviewed the MAR indicated [REDACTED]. Nurse #2 said that check off indicated that the resident consumed the entire 120 cc amount and that figure should be entered on the daily I & O worksheet. On 1/3/12 at 10:12 P.M., the nurse documented that the physician was contacted because the results of the urine culture were back. The physician changed the antibiotic and ordered an ultrasound for the following morning. No blood work was ordered. According to the 1/4/12 11-7 shift notes, the physician was contacted multiple times because the resident's temperature continued to be elevated: 100.1 at 12:00 A. M, 102.4 at 2:00 A. M, and 101.5 at 4:00 P.M. despite being medicated with [MEDICATION NAME] (fever reducer). The physician ordered blood work, blood cultures and a chest x-ray which were completed. The resident had no intake on the 11 - 7 shift. During the initial tour on 1/4/12 at approximately 9:15 A.M., Resident #9 was observed lying flat on his/her back with the bed in the low position. The resident's mouth was open and his/her lips were observed to be dry. A white cloth was draped across the resident's forehead. The resident did not respond to verbal stimuli. Nurse #2, said that the resident was being treated for [REDACTED]. Nurse #2 said the physician ordered a chest x-ray which was positive for pneumonia and blood work was drawn, with the results pending. Nurse #2 said that the physician planned to visit the resident. The resident was observed again on 1/4/12 at 1:30 P.M. The resident was lying on his/her back with the bed in the low position. The resident's mouth was open and a white cloth was draped across his/her forehead. The resident did not respond to his/her name from a certified nurse aide (CNA) who had entered the room. During record review on 1/4/12 at 2:00 the surveyor located the results of the pending blood work that had been faxed to the facility at 10:12 AM on the nurses desk. Review of the findings revealed the following abnormal values which can be indicative of dehydration. dehydrated: Sodium 159 high (range 133-145) Chloride 121 high (range 96-108) BUN 33 high (range 10-24) Nurse #2 was asked on 1/4/12 at 2:15 P.M. about the resident's status. She said that the resident was responsive to name but remained "sleepy" most of the time. She said that she was "able to wake the resident up" to give his/her medications which included the new antibiotic ordered for the resident's pneumonia. Nurse #2 said that the resident's intake was 600 cc's and the 11-7 shift I &O indicated that the resident had no intake. She did not know what the estimated 24 hour fluid intake should be for Resident #9. Nurse #2 was not aware the results had been faxed to the facility. On 1/4/12 at approximately 2:55 P.M., the Director of Nurses (DNS) approached the surveyor because she understood that the surveyor had questions regarding the status of Resident #9. The surveyor informed the DNS that the blood work results indicated that the resident was dehydrated and asked what the plan was to address the resident's status. The DNS then accompanied the surveyor to observe Resident #9 who was again observed lying flat on his/her back with the bed in the low position. The resident's mouth remained open. A white cloth remained draped over the resident's forehead. The DNS was informed that this was the third time that the resident was observed in the same position. After observing the resident the DNS said, "I can see why you are concerned. I'll take care of it." Following surveyor inquiry, Nurse #2 reported that the physician was contacted and gave new orders to start IV hydration. The infusion company was contacted and arrived within 45 minutes but were informed on arrival that the facility staff had already inserted the intravenous line. The resident was visited by the physician during the evening of 1/4/12. The physician reported that the resident was receiving double antibiotics for the treatment of [REDACTED]. The physician also reported that the resident had dehydration with intravenous hydration ordered at 75 cc's per hour. Additional orders included repeating the blood work the following day and to monitor the resident's I & O. On 1/9/12 at 9:30 A.M. the surveyor interviewed the DNS. The DNS said that she completed a review of Resident #9 and presented a care plan, developed 1/5/12, for "Potential for Alteration in Hydration". The DNS said that the plan included for staff to assess the resident's skin turgor and mucus membranes for signs of proper hydration. The DNS said that the I & O monitoring process was not comprehensive and was in the process of being "tweaked" via the facility's care tracker. The DNS did not know what the resident's estimated daily fluid intake should be in order for staff to gauge if the resident was receiving sufficient fluids. The DNS said that she would clarify the estimated fluid needs for Resident #9. Just prior to the exit conference on 1/10/12 at 1:45 P.M. the surveyor was given an updated care plan for dehydration dated 1/10/12, this plan inaccurately stated that the resident 24 hour fluid intake should be 1200 cc's. See F 514