Every finding on record at Gardner Rehabilitation and Nursing Center

Based on observation and interviews, the facility failed to store all medications in a safe and secure manner in one central supply room (South Two Unit), out of two central supply rooms in the facility, and one Nursing Unit (East One). Specifically, the facility failed to ensure that the central supply room on the South Two Unit was locked on 1/28/26, allowing residents, visitors, and unauthorized staff ready access to over-the-counter medications. 2.the facility failed to ensure that two plastic bags containing muscle relaxant, diuretic, and psychotropic medications were appropriately stored on the East One Unit, placing unauthorized staff, visitors and facility residents at risk for accessing the medications. Findings include: Review of the facility's policy titled Medication Storage, dated 4/9/25, indicated but was not limited to the following: -Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper.security. -Policy Explanation and Compliance Guidelines: > All drugs.will be stored in locked compartments (For example:.medication rooms). > Only authorized personnel will have access to the keys to locked compartments. On 1/28/26 at 9:08 A.M., during a medication administration pass, the surveyor observed Nurse #6 open the unlocked door to the central supply room on the South Two Unit in an attempt to locate Vitamin E. The central supply room contained an unlocked cabinet where several over-the-counter medications including but not limited to: Aspirin, Melatonin (supplement to assist in treating sleep disorders), Nicotine patches, Ibuprofen, and Acetaminophen were stored. During an interview at the same time, Nurse #2 said the door to the central supply room was unlocked at the time of her entrance into the room. Nurse #6 said she did not have a key to access the central supply room and she had encountered the central supply room unlocked a couple of times on other occasions. Nurse #6 said the unlocked door to the central supply room was a concern because it would allow anyone access to the medications. During an interview on 1/28/26 at 3:20 P.M., the Medical Records and Central Supply Staff said that only herself, maintenance staff, Nurses and Unit Managers should have access to the central supply rooms. She said the expectation was that the central supply rooms were locked and required key access. The Medical Records and Central Supply Staff said the cabinet storing the over-the-counter medications had a lock but did not have a lock at this time. She said the importance of the door to the central supply room on the South Two unit being locked was that there were over-the-counter medications stored in the room, including Tylenol and Melatonin. The Medical Records and Central Supply Staff said the overnight staff would leave the door unlocked and once or twice she had encountered the door to the central supply room on the South Two unit unlocked. During an interview on 1/29/26 at 8:19 A.M., the Director of Nursing (DON) said the expectation was that the central supply room doors were locked at all times, to restrict access to unauthorized persons. The DON said that residents should not have access to medications that were not ordered for them by the Physician. The DON said that in addition, he did not want a resident to wander into the unlocked central supply room and go missing. 2. On 2/2/26 between 9:25 A.M. and 9:40 A.M., the surveyor observed the following on the East One Unit nurses station: -No staff were present at the nurses station between 9:25 A.M. and 9:30 A.M. -One purple plastic bag was laying on the nurses station desk and contained 20 tablets of Baclofen (muscle relaxant medication) 10 mg tablets and 10 tablets of Spironolactone (diuretic medication) 25 mg tablets. -One white plastic bag was laying on the East One Shred-It box and contained 10 tablets of Mirtazapine (antidepressant/psychotropic medication) and 20 tablets of Trazodone (antidepressant/psychotropic medication) 50 mg tablets. -Between 9:30 A.M. and 9:40 A.M., Rehab Staff #1 arrived at the nurses station desk and was observed writing on paper while standing over the desk. Both the white and purple plastic bags remained at the nurses station, unsecured, and within Rehab Staff #1's proximity. -Between 9:35 A.M. and 9:40 A.M., Unit Clerk #1 arrived at the nurses station and began to conduct her work. Both the white and purple plastic bags remained at the nurses station, unsecured, and within proximity to Unit Clerk #1. During an interview on 2/2/26 at 9:41 A.M., Unit Manager (UM) #1 said all medications should be locked and secured on the East One Nursing unit in the medication room or in a medication cart. UM #1 said that only Nurses should have access to medications. The surveyor and UM #1 observed the white and purple plastic bags containing the medications at the nurses station with Unit Clerk #1 and Rehab Staff #1 present. UM #1 said that the medications had been packaged and left out for return to the pharmacy today but should have been put back into the medication room until pharmacy staff arrived. UM #1 said that the medications should not be left out because unsecured medications could be accessed by wandering residents, non-licensed staff or visitors.

Based on observations, interviews, and record reviews the facility failed to ensure that professional standards of practice in delivery of care and services were being met for seven Resident's (#3, #5, #32, #15, #113, #108, and #2) out of a total sample size of 24 residents. Specifically, 1.For Resident #3, the facility failed to ensure that a Physician's order for CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) laboratory testing was obtained as ordered, placing Resident #3 at risk for worsening medical conditions. 2. For Resident #5, the facility failed to administer Insulin medication (Lispro) as prescribed by the Physician for 24 doses over a 19-day period and notify the Resident's Physician that the Resident's Lispro had not been administered as prescribed, placing Resident #5 at risk for variable blood sugar levels. 3. For Resident #32, the facility failed to ensure that output monitoring (any fluids leaving the body) was completed as Physician ordered for 15 days during a 21-day period, placing Resident #32 at risk for complications related to fluid imbalance. 4. For Resident #15, the facility failed to administer Enalapril Maleate (high blood pressure medication) as ordered on two non-consecutive dates, increasing the Resident's risk for medical complications.5. For Resident #113, the facility failed to administer Midodrine Hydrochloride [HCL] (orthostatic hypotension medication) as ordered on two non-consecutive dates, increasing the Resident's risk for medical complications.6. For Resident #108, the facility failed to ensure that repositioning and incontinence care was provided as documented by nursing staff on two separate occasions (8:00 A.M. and 10:00 A.M.) on 1/28/26, when the Resident was dependent on staff for ADL care and was at risk for skin impairment due to immobility.7. For Resident #2, the facility failed to ensure that Physician orders were followed for Furosemide (diuretic [increases urination] medication), Metoprolol Succinate Extended Release [ER] (high blood pressure medication), and Spironolactone (diuretic medication) when the order indicated to hold (not administer) the medications when the Resident's systolic blood pressure (SBP - top number of a blood pressure reading), was measured less than 110 mmHg (millimeters of mercury) and/or heart rate was less than 55 bmp (beats per minute). Findings Include: 1. Review of the facility policy titled Provision of Physician Ordered Services, dated 2/25/25 included but was not limited to the following: >The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the Physicians orders. >Qualified nursing personnel will submit timely requests for Physician ordered services to the appropriate entity. Resident #3 was admitted to the facility in January 2026 with diagnoses including stricture (narrowing) of Artery, chronic vascular disorders of intestine and Clostridium Difficile (C-diff: bacteria that can cause severe watery diarrhea and bloody stools that could result in dehydration, loss of appetite, blood loss, weight loss, fever and pain). Review of Resident #3's Medical Record included but was not limited to: -Resident #3 was prescribed Apixaban (blood thinning medication that increases the risk for bleeding) 5 mg (milligrams) by mouth twice a day, effective 1/8/26. -Resident #3 was prescribed Vancomycin (antibiotic used to treat Clostridium Difficile) 125 mg by mouth once a day, effective 1/8/26 -Physician's order for CBC and BMP weekly x (times) two weeks on 1/9/26 and 1/16/26, effective 1/8/26. -Evidence of a laboratory report dated 1/9/26 which indicated the following abnormal results: >Blood [NAME] Nitrogen (BUN: measurement of the urea nitrogen in the blood) = 9 mg/deciliter (dl) which was below the normal reference range of 10 - 24 mg/dl. >Creatinine (waste product that the kidneys filter from the blood) = 0.62 mg/dl which was below the normal reference range of 0.70 - 1.50 mg/dl. >Total Protein (concentration of protein in the blood serum) = 5.5 gram (g)/dl which was lower than the normal reference range of 6.4 - 8.3 g/dl. >Hemoglobin (protein that helps carry oxygen to the body's organs and tissues) = 10.9 g/dl which was lower than the normal reference range of 12.1 - 15.7 g/dl. >Hematocrit (volume percentage of red blood cells in the blood) = 33.2% which was below the normal reference range of 35 - 45%. Review of Resident #3's Person - Centered Care Plan included but was not limited to the following: -Resident #3 was at risk for increased/abnormal bleeding due to the use of Apixaban with interventions including obtaining labs as ordered and reporting results to the Medical Doctor, initiated 1/10/26. Further review of Resident #3's Medical Record failed to indicate any evidence that the CBC and BMP laboratory testing ordered on 1/8/26 was obtained as ordered for 1/16/26. During an interview on 2/2/26 at 9:45 A.M., Unit Manager (UM) #1 said that Resident #3 did not have his/her blood work drawn on 1/16/26 as ordered by the Physician. UM #1 said the floor Nurse did not complete the electronic requisition for both dates of ordered blood work when transcribing the order on 1/8/26. UM #1 said that the electronic requisitions are needed so that the laboratory would know to come to the facility to collect the blood sample on the correct day. UM #1 said that the ordered lab work was important for Resident #3 to monitor baseline labs because the Resident's blood work from 1/9/26 had previously been abnormal and therefore placed Resident #3 at risk for unidentified worsening of lab results. 2. Review of the facility policy titled Timely Administration of Insulin, revised 4/9/25, included but was not limited to the following: -It is the policy of this facility to provide timely administration of Insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. >all Insulin will be administered in accordance with physician's orders. Review of the facility policy titled Medication Administration, dated 4/9/25 included but was not limited to the following: >Report and document any held (not administered) medications to the Physician/Nurse Practitioner/Physician Assistant. Resident #5 was admitted to the facility in January 2026 with diagnoses including Diabetes. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/26 indicated Resident #5: -had moderate cognitive impairment as evidenced by a Brief interview of Mental Status (BIMS) score of 11 out of a total possible score of 15. -had a diagnosis of Diabetes. -was administered Insulin. Review or Resident #5's Person-Centered Care Plan initiated on 1/9/26 included but was not limited to: -Diabetes, at risk for hypo (low)-hyper (high) glycemia (presence of glucose in the blood) with interventions including: >providing medications as ordered. Review of the Resident #5's January 2026 Physician orders included but was not limited to: -Lispro Insulin Injection Solution 100 unit/milliliter (ml) inject 5 units subcutaneously (below the skin) three times a day at 8:00 A.M., 12:00 P.M., and 6:00 P.M., for Diabetes, start date 1/9/26. Review of Resident #5's January 2026 Medication Administration Record (MAR) indicated that Resident #5 was not administered Lispro Insulin Injection Solution as prescribed on the following dates and times: -1/11/26, 1/12/26, 1/15/26, 1/16/26, 1/17/26,1/18/26, 1/20/26, 1/21/26, 1/23/26, 1/26/26 at 8:00 A.M. -1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/21/26, 1/22/26, 1/26/26 at 12:00 P.M. -1/9/26, 1/17/26, 1/18/26, 1/19/28, 1/20/26, 1/27/26 at 6:00 P.M. Review of Resident #5's Medical Record included but was not limited to the following: -No evidence of medication parameters (when to administer or to withhold administration) relative to Lispro Insulin Injection Solution. -No evidence that the Resident's Physician had been notified about the 24 doses of Lispro Insulin not administered to Resident #5. During an interview on 1/28/26 at 1:59 P.M., Unit Manager (UM) #1 said that Resident #5 should have been administered Insulin Lispro 5 units three times a day as ordered by the Physician. The surveyor and UM #1 observed the Resident's MAR and UM#1 said the Resident did not have parameters in place to hold the Lispro Insulin. UM #1 said that she was unable to provide evidence that the Nurses who did not administer the Resident's Lispro Insulin doses had notified the Resident's Physician, but they should have. UM #1 said that Resident #5 could be at risk for mental status changes or hypoglycemia [sic] episodes when not receiving his/her Insulin as ordered. 3. Review of the facility policy titled Hydration, dated 12/2/25 included but was not limited to the following: -The facility offers each resident sufficient fluid (the amount of fluid needed to prevent dehydration and maintain health). >Documentation: Record output in designated locations (Medication Administration Record [MAR] or Output Record). Resident #32 was admitted to the facility in January 2026 with diagnoses including Congestive Heart Failure and obstructive and reflux (backflow) uropathy. Review of Resident # 32's January 2026 Physician's orders included but was not limited to: -Foley Catheter (specific type of soft flexible tube that drains urine from the bladder) 24 French (5.5 millimeter diameter)/10 milliliter balloon (fluid filled balloon at the end of the catheter which anchors the catheter in place in the bladder) every shift, start date 1/8/26. -Furosemide 40 milligrams (mg) one time a day for diuresis. -Spironolactone Oral Tablet 25 mg by mouth once a day for diuresis. -Document intake (fluids taken into the body) and output every shift, start date 1/16/26. Review of Resident #32's Person-Centered Care Plan included but was not limited to: -Urinary Foley catheter related to Urine Retention with interventions including monitoring and documenting output, initiated 1/8/26. -Potential for fluid deficit related to diuretic use with interventions including Physician notification for persistent output exceeding intake in the past 48 hours. Review of the Minimum Data Set (MDS) Assessment, dated 1/8/26 indicated Resident #32: -has an indwelling urinary catheter. -was administered diuretics. Review of Resident #32's Treatment Administration Record (TAR) for January 2026 included but was not limited to: -incomplete documentation of Output recordings for seven days over a 12-day period between 1/8/26 - 1/19/26. -omitted documentation of Output recordings for nine days over a nine-day period between 1/20/26 - 1/28/26. During an interview on 1/29/26 at 10:27 A.M., UM #1 said Resident #32 had a current Physician's order to monitor and document Intake and Output (I & O) because the Resident had a urinary catheter in place. UM #1 said that each Nurse assigned to the Resident should document I & O every shift (11:00 P.M. - 7:00 A.M., 7:00 A.M. - 3:00 P.M., and 3:00 P.M. - 11:00 P.M.). The surveyor and UM #1 reviewed Resident #32's medical record and UM #1 said that the Resident's output documentation from 1/8/26 - 1/19/26 was incomplete and there was no evidence for output documentation recorded for 1/20/26 through 1/28/26. UM #1 said that output documentation was important for Resident #32 because not monitoring output could place Resident #32 at risk for fluid overload or dehydration. 4. Resident #15 was admitted to the facility in August 2025 with diagnoses including Dementia and Chronic Kidney Disease. Review of Resident #15's Physician's orders, dated 10/17/25 and discontinued 11/18/25, indicated: Enalapril Maleate Oral Tablet 20 mg; give one tablet by mouth in the morning for Hypertension (HTN). Hold for SBP below or equal to 110 mmHg. Review of Resident #15's Minimum Data Set (MDS) Assessment, dated 11/5/25, indicated the Resident was severely cognitively impaired as evidenced by a BIMS score of five out of 15 total possible points. Review of Resident #15's October 2025 and November 2025 Medication Administration Records (MARs) indicated: -The Resident's SBP was 106 mmHg (below 110) on 10/25/25 at the time Enalapril Maleate was due to be administered. -Enalapril Maleate was administered to the Resident on 10/25/25. -The Resident's SBP was 110 mmHg on 11/3/25 at the time Enalapril Maleate was due to be administered. -Enalapril Maleate was administered to the Resident on 11/3/25. 5. Resident #113 was admitted to the facility in January 2025 with diagnoses including Dementia and Hypotension. Review of Resident #113's Minimum Data Set (MDS) Assessment, dated 12/17/25, indicated the Resident was severely cognitively impaired as evidenced by a BIMS of eight out of 15 total possible points. Review of Resident #113's Physician's orders, dated 3/25/25 with no end date, indicated: -Midodrine HCL Oral Tablet 2.5 mg, give one tablet by mouth in the morning for management of Hypotension. Hold for SBP greater than 130. Review of Resident #113's November 2025 and December 2025 MARs indicated: -The Resident's SBP was 130 mmHg on 11/6/25 at the time Midodrine HCL was due to be administered. -Midodrine HCl was not administered to the Resident and was indicated as 4 (vitals outside of parameters for administration). -The Resident's SBP was 134 mmHg (greater than 130) on 12/4/25 at the time Midodrine HCL was due to be administered. -Midodrine HCl was administered to the Resident on 12/4/25. During an interview on 1/30/26 at 2:29 P.M., the Director of Nursing (DON) said he reviewed both Residents #15's and Resident #113's clinical records and that Enalapril Maleate was administered to Resident #15 outside of the Physician ordered parameters on 10/25/25 and 11/3/25. The DON further said Midodrine HCl was administered to Resident #113 outside of the Physician ordered parameters on 11/6/25 and 12/4/25. The DON also said all medications should be administered to Residents according to the Physician's orders. 6. Resident #108 was admitted to the facility in April 2022 with diagnoses including cognitive impairment and need for assistance with personal care. Review of the Minimum Data Set (MDS) Assessment, dated 11/5/25, indicated Resident #108: -was severely cognitively impaired as evidenced by a BIMS score of six out of 15 total possible points. -was dependent on staff for bathing, dressing, toileting hygiene, and transfers. -required the use of a wheelchair. -was always incontinent of bowel and bladder. Review of Resident #108's active Care Plan indicated: -was incontinent of bowel and bladder related to Dementia. -has an ADL deficit and was dependent upon two staff members for bathing, dressing, bed mobility, and personal hygiene. -Clean peri-area with each incontinent episode. -was at risk for potential skin impairment due to impaired mobility, impaired safety and judgment, obesity, and incontinence. On 1/28/26, from 7:45 A.M. until 11:49 A.M., the surveyor observed Resident #108 seated in his/her wheelchair in the East Two Unit Dining Room. The surveyor failed to observe any staff repositioning and providing incontinence care to Resident #108 during the observation period where the Resident remained seated in his/her wheelchair in the East Two Unit Dining Room. Review of Resident #108's Certified Nurse Aide (CNA) Flow Sheets, dated 1/28/26, indicated: -The Resident was dependent upon two staff, and was boosted and turned to his/her right side in bed at 8:00 A.M. and 10:00 A.M. -The Resident was dependent upon two staff, and was incontinent of urine at 8:00 A.M. and 10:00 A.M. During an interview on 1/29/26 at 9:55 A.M., CNA #2 said she worked on the East Two Unit on 1/28/26 for the day (7:00 A.M. through 3:00 P.M.) shift and that she had been responsible to provide care for Resident #108. CNA #2 said she did not provide repositioning and incontinence care for Resident #108 any time after she assisted the Resident out of bed in the morning on 1/28/26. During an interview on 1/29/26 at 2:50 P.M., the Director of Nursing (DON) said CNA's were supposed to record the care that they provided to residents. The DON said CNA #2 should have recorded the care provided for Resident #108 on the 1/28/26 day shift and should not have recorded care that was not provided for the Resident. 7. Review of the facility policy titled Vital Signs, dated 12/2/25, included but not limited to:*The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs.-Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. -Vital signs will be obtained by the nurse or therapist, as indicated, when administering certain medications, or monitoring for effectiveness of medications or therapies. For Example, >Certain cardiac drugs are given only when a resident's pulse or blood pressure is within certain range. Resident #2 was admitted to the facility in October 2025, with diagnoses including Left Bundle Branch Block (LBBB - heart condition), presence of cardiac pacemaker, unspecified Diastolic Congestive Heart Failure, Non-ST Elevation Myocardial Infarction, and paroxysmal Atrial Fibrillation. Review of the Minimum Data Set (MDS) Assessment, dated 11/17/25, indicated Resident #2: -was able to make him/herself understood, and he/she understood others with clear comprehension. -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. Review of Resident #2's Physician orders dated 1/28/26, indicated:-Furosemide Oral Tablet 20 milligrams (mg), give 1 tablet by mouth one time a day for Congestive Heart Failure (CHF), Hold if systolic blood pressure (SBP) is less than 110 mmHg, initiated 11/26/25.-Metoprolol Succinate Extended Release (ER) tablet 24-hour 50 mg. Give 1 tablet by mouth one time a day for Hypertension (HTN). Hold for SBP less than 110 mmHg, or HR (heart rate) less than 55 bpm, initiated 11/19/25. -Spironolactone Oral tablet 25 mg, give 1 tablet by mouth one time a day for CHF. Hold for SBP less than 110 mmHg or HR less than 55 bpm, initiated 11/19/25. Review of Resident #2's November 2025 through January 2026 Medication Administration Records (MARs) indicated the following: 1. Furosemide 20 mg was signed off as administered by nursing staff when the SBP was less than 110 mmHg on the following dates: -11/27/25: SBP reading 88 mmHg-11/30/25: SBP reading 96 mmHg -12/18/25: SBP reading 106 mmHg-12/28/25: SBP reading 94 mmHg-1/11/26: SBP reading 107 mmHg-1/14/26: SBP reading 103 mmHg-1/18/26: SBP reading of 106 mmHg-1/21/26: SBP reading of 108 mmHg-1/23/26: SBP reading of 102 mmHg-1/28/26: SBP reading of 107 mmHg 2. Metoprolol Succinate Extended Release (ER) tablet 24-hour 50 mg was signed off by Nursing staff as administered when the SBP was less than 110 mmHg on the following dates: -11/3/25: SBP reading 101 mmHg-11/13/25: SBP reading 100 mmHg-11/14/25: SBP reading 98 mmHg-11/15/25: SBP reading 96 mmHg-11/30/25: SBP reading 96 mmHg -12/18/25: SBP reading 106 mmHg-12/28/25: SBP reading 94 mmHg-1/11/26: SBP reading 107 mmHg-1/14/26: SBP reading 103 mmHg-1/18/26: SBP reading 106 mmHg-1/20/26: SBP reading 105 mmHg-1/21/26: SBP reading 108 mmHg-1/23/26: SBP reading 102 mmHg-1/28/26: SBP reading 107 mmHg 3. Spironolactone Oral tablet 25 mg was signed off by Nursing staff as administered when the SBP was less than 110 mmHg on the following dates: -11/30/25: SBP reading 96 mmHg -12/18/25: SBP reading 106 mmHg-1/11/26: SBP reading 107 mmHg-1/14/26: SBP reading 103 mmHg-1/18/26: SBP reading 106 mmHg-1/21/26: SBP reading 108 mmHg-1/22/26: SBP reading 94 mmHg-1/23/26: SBP reading 102 mmHg-1/28/26: SBP reading 107 mmHg During an interview on 1/28/26 at 2:28 P.M., the surveyor and the Unit Manager (UM) #1 reviewed Resident #2's MAR for November 2025, December 2025 and January 2026, and observed the days in each month that Resident #2 was administered blood pressure and diuretic medications when the Resident's SBP reading was less than 110 mmHg. UM #1 said that the Physician orders indicated to hold the blood pressure medication if the Resident's SBP was less than 110 mmHg and heart rate less than 55 bpm. UM #1 said that the check mark on the MAR for November 2025, December 2025 and January 2026, indicated that the medications were administered and should have been held when the Resident's SBP was less than 110 mmHg. UM #1 said there would be an increased risk of Resident #2 experiencing hypotension (low blood pressure) which could lead to dizziness and falls when he/she was administered the Furosemide, Metoprolol and Spironolactone medications when the SBP was less than 110 mmHg. During an interview on 1/28/26 at 2:56 P.M., the Director of Nursing (DON) said it was his expectation that the nursing staff follow Physician orders when administering medications. The DON said Resident #2's blood pressure medications should not have been administered to the Resident when his/her SBP was less than 110 mmHg. The DON said when the nursing staff administered the Furosemide, Spironolactone and Metoprolol medication to Resident #2 when his/her SBP was less than 110 mmHg there was a potential that the Resident's blood pressure could decrease which could lead to hospitalization.

Based on observations, record reviews, and interviews, the facility failed to complete an assessment for medication self-administration for one Resident (#4), out of a total sample of 24 residents. Specifically, for Resident #4, the facility failed to ensure that the Resident was assessed for his/her ability to safely and appropriately self-administer medications when unlabeled tablets in a medication cup were observed left at his/her bedside to be self-administered. Findings include:Review of the facility policy titled Medication Administration, last revised dated 4/9/25, included but not limited to: *Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -observe resident consumption of medication. Review of the facility policy titled Medication Storage, dated 4/9/25, included but not limited to:*It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -All drugs and biologicals will be stored in locked compartments (that is (i.e.,) medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control.-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Resident #4 was admitted to the facility in January 2022 with diagnoses including Major Depressive Disorder, Chronic Kidney Disease Stage 5, Dependence of Renal Dialysis, Type 2 Diabetes Mellitus, and Hypertension. Review of Resident #4's Minimum Data Set (MDS) Assessment, dated 12/18/25, indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. On 1/29/26 at 8:53 A.M., the surveyor observed Resident #4 seated in a wheelchair in his/her bedroom. A plastic medication cup containing two large white tablets, one small red tablet and one small white tablet were observed on the Resident's bedside table which was positioned next to him/her. During an interview at the time, Resident #4 said that the medications in the plastic cup were his/her morning medications that Nurse #1 left for him/her to self-administer. Resident #4 said that the two large tablets were his/her dialysis medications. During an interview on 1/29/26 at 9:00 A.M., Nurse #1 said that the medication cup the surveyor observed on Resident #4's bedside table contained the following scheduled morning medications:-Renvela (phosphate binder) Oral Tablets 800 milligrams [mg] (the two large white tablets - dialysis medication used to control high phosphorus levels in chronic kidney disease).-Famotidine (H2-receptor blocker) Oral Tablet 20mg (one white small tablet- medication that reduces stomach acid production to treat heartburn, acid reflux and stomach ulcers). -Multi-Vitamin (one red tablet).Nurse #1 further said the Resident's medication should not have been left at the Resident's bedside table for him/her to self-administer. Nurse #1 said there was a risk that Resident #4 may not have taken the medication, could have thrown the medication away and/or a risk of another resident taking the medications for themselves. Nurse #1 also said that the risk of Resident #4 not taking his/her scheduled dialysis medication was dangerous as it could lead to toxins building up and increase the Resident's risk of being hospitalized . Nurse #1 said Resident #4 did not have a Physician's order to self-administer his/her medications and had not been evaluated to self-administer his/her medications. Review of Resident #4's clinical records failed to indicate any evidence that assessment for self-administration of medications was completed for the Resident. During an interview on 1/29/26 at 1:00 P.M., the Director of Nursing (DON) said it was his expectation that the nursing staff administer medications to Residents and that the medications were not left at the Resident's bedside. The DON said the medications that were left at Resident #4's bedside included his/her dialysis medication, and the dialysis medication was important for the Resident to take to prevent toxins from building up in his/her blood leading to potential hospitalization. The DON said when the medications were left unattended by Nurse #1, Resident #4 could also have thrown away the medications or given the medications to another resident. The DON said there were other residents who wandered on Resident #4's unit and there was a potential risk that other residents might have wandered into the Resident's room and consumed the Resident's medication. The DON further said that Resident #4 had not been assessed for self-administration of medications, and it was his expectation for nursing staff to stay with the Resident to ensure that he/she took their medication safely prior to the Nurse leaving the Resident's room.

Based on record review and interview, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#13) out of a total sample of 24 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) Form on record was valid and reflected the signature of Resident #13's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) after the Physician had determined that the Resident lacked the capacity for informed medical decision making. Findings include: Review of the facility policy for Resident's Rights Regarding Treatment and Advanced Directives, last revised 3/25/25, indicated:-On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. -The facility will periodically assess the resident for decision-making abilities and approach the HCP or legal representative if the resident is determined not to have decision making capacities.-During the care planning process, the facility will identify, clarify and review with the resident or legal representative whether they desire to make any changes related to advanced directives. -Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Resident #31 was admitted to the facility in December 2024, with diagnoses including Dementia and repeated falls. Review of Resident #13's clinical record indicated:-a MOLST Form signed on 12/17/24 by Resident #13's HCP.-a HCP Activation Form dated 3/3/25 (after the MOLST Form had been signed by the HCP).-no evidence that the MOLST Form had been re-addressed with Resident #13's HCP after admission to the facility and prior to the surveyor bringing it to the facility's attention. During an interview on 1/29/26 at 1:29 P.M., the Social Worker (SW) said that the MOLST Form was not valid because it had been signed by the HCP prior to the Physician invoking the HCP. The SW also said that Resident #13 was still their own decision maker at that time and should have been the one to sign the MOLST Form. During an interview on 1/29/26 at 1:45 P.M., the Director of Nursing (DON) said that the MOLST Form was not valid and that the facility will get a new MOLST Form signed by the HCP now that it had been activated. The DON also said that it was important to have the primary decision maker review the MOLST Form to make sure that their wishes are being followed.

Based on record review, and interviews, the facility failed to resolve a grievance timely for two Residents (#13 and #121) out of a total sample of 24 residents.Specifically, the facility failed to ensure:1. for Resident #13, that a report of missing reading glasses was identified as a grievance and was resolved within a reasonable time frame.2. for Resident #121, that the Resident Representative (RR #1) was provided with the conclusion and corrective action to a documented grievance as required. Findings include: 1. Resident #13 was admitted to the facility in December 2024 with diagnoses including Dementia, Type 2 Diabetes and repeated falls. Review of Resident #13's clinical record indicated the following Nursing Progress Notes: -12/5/24: Client uses glasses.which he/she has with him/her. -2/2/25: Resident attending activities in the day room. Concerned on missing glasses. Supervisor is aware of ongoing concern. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -the Resident was moderately cognitively impaired as evidenced by a BIMS score of 8 out of a possible score of 15. -the Resident's vision was adequate and he/she utilized corrective lenses (contacts, glasses or magnifying glass) for vision. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -the Resident was severely cognitively impaired as evidenced by a BIMS score of 6 out of a possible score of 15. -the Resident's vision was adequate and he/she did not utilize corrective lenses (contacts, glasses or magnifying glass) for vision. During an interview on 1/27/26 at 8:54 A.M., Resident #13 said that he/she was missing his/her reading glasses. Review of the facility's 2025 Grievance Log failed to indicate that a Grievance Form had been completed on behalf of Resident #13 for their missing reading glasses. Review of Resident #13's clinical record indicated: -no evidence that a grievance had been filed or that any follow-up had occurred for the Resident's missing reading glasses. -a Social Services Progress Note dated 1/28/26, which documented Resident #13's family member confirming that the Resident has been prescribed reading glasses, but that the eyeglasses had been seen with the Resident for over a year. During an interview on 1/29/26 at 11:16 A.M., the Administrator said that Resident #13's missing reading glasses had not been brought to his attention by staff and that the missing glasses should have been brought to his attention because the facility staff discuss grievances daily during their morning meetings. The Administrator also said that the facility should have filed a Grievance Form on behalf of Resident #13 and that the facility had not addressed the Resident's concern. 2.Resident #121 was admitted to the facility in May 2023 with diagnoses including Dementia. Review of Resident #121's Minimum Data Set (MDS) Assessment, dated 10/16/25, indicated: -The Resident sometimes understood others and was sometimes understood. -The Resident was unable to complete the BIMS examination and had severely impaired cognitive skills for daily decision making. -The Resident required substantial assistance to dependence from staff for activities of daily living (ADLs). Review of the facility's 2025 Grievance Log indicated a Grievance Form, dated 10/31/25, filed with the facility by Resident #121's Representative (RR #1) which indicated: -RR #1 was concerned that ADL care had not been provided to Resident #121 in a timely manner. -RR #1 was concerned that staffing was not adequate for resident acuity. Further review of the 10/31/25 Grievance Form failed to include any evidence that the facility's conclusion and corrective actions following the investigation were communicated to RR #1. During an interview on 1/27/26 at 4:22 P.M., RR #1 said he/she filed a grievance with the facility relative to his/her concern that the facility did not have enough staff to adequately assist residents, including Resident #121, timely with ADL care. RR #1 said he/she never received a response back from the facility relative to the facility's conclusion and corrective actions following their investigation into his/her grievance and that the facility had not adequately addressed his/her concern for inadequate staffing. During an interview on 1/28/26 at 4:45 P.M., the Administrator said that he and the Social Worker (SW) worked together when investigating grievances. The Administrator said that following the completion of a grievance investigation, the individual who filed the grievance would be notified of the grievance conclusion and corrective actions. The surveyor and the Administrator reviewed RR #1's 10/31/25 Grievance Form and the Administrator said the section of the Form to be completed relative to the grievance conclusion and correctives actions was not recorded. The Administrator said he would review Resident #121's record to identify whether there was any evidence the conclusion and corrective actions relative to RR #1's 10/31/25 grievance had been communicated to RR #1. The facility failed to provide any evidence to the survey team prior to survey exit that the conclusion and corrective actions relative to RR #1's 10/31/25 grievance had been communicated to RR #1. Please Refer to F658 and F725.

Based on observations, interviews, and records reviewed, the facility failed to identify hazardous hot water temperatures in four shower rooms (East One, East Two, South One, and South Two) out of a total of five shower rooms in the facility, and for two Resident's (#20 and #22) with hot water concerns, increasing the risk for accidental burns to residents and staff in the facility. Specifically, the facility failed to identify hazardous hot water temperatures and implement interventions: -in one of the East One Unit's shower rooms when the shower room's shower head with built-in temperature gauge indicated a hot water temperature of 140 degrees ( ) Fahrenheit (F). -in the East Two Unit's shower room when the shower had a manual hot water temperature of 126 F. -in the South One Unit's shower room when the shower had a manual hot water temperature of 121.1 F, and the shower head with built-in temperature gauge indicated a hot water temperature of 69 F.-in the South Two Unit's shower room when the shower had a manual hot water temperature of 131 F. -in Resident #20's bathroom sink, when the Resident's bathroom sink had a manual hot water temperature measured at 134.6 F. -when Resident #22 reported the water temperature concerns during Resident Council. Findings include: Review of the facility's policy titled Domestic Hot Water Policy, undated, indicated but was not limited to the following: -Purpose: This policy ensures domestic hot water is delivered safely, reliably, and in compliance with healthcare standards to prevent scalding . -Scope: Applies to all domestic hot water systems serving resident rooms, bathing areas . -Temperature standards: >Point-of-use bathing fixtures: Less than or equal to 110 F. -Monitoring: Routine monitoring and documentation shall be completed by Maintenance staff per schedule. -Unsafe conditions response: Immediate corrective action is required for unsafe temperatures or hot water outages. Review of the facility's Water Temperature Logs, dated 12/2/24 through 1/26/26, indicated: -Weekly hot water checks were performed on all four units (East One, East Two, South One, and South Two) with temperatures ranging from 105.0 F to 108.4 F. -No evidence on the specific locations for each unit where hot water temperature checks were performed, including whether the Unit shower rooms were checked. Review of the facility's Resident Council Meeting Minutes indicated that hot water had been discussed during the December 2025 and January 2026, Resident Council meetings, including the installation of hot water boosters. During the Resident Council Interview conducted on 1/28/26 at 1:45 P.M., the following information was provided: -Resident #20 said the water can be boiling hot at times. -Resident #22 said the Resident Council had informed the facility of ongoing water temperature concerns. Resident #20 was admitted to the facility in January 2023. Review of the MDS dated [DATE] indicated Resident #20: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. -was independent with oral hygiene. -was independent with toileting hygiene. -required setup or clean-up assistance with showering/bathing. -was independent with personal hygiene (including washing/drying face and hands.) -was independent with walking 150 feet. Resident #22 admitted to the facility in January 2018. Review of the Minimum Data Set (MDS) Assessment, dated 1/28/26, indicated Resident #22: -did not have a short-term memory deficit. -independently made consistent/reasonable decisions regarding tasks of daily life. -did not have disorganized thinking. -did not have a BIMS exam completed. During an interview on 1/29/26 at 3:50 P.M., the Maintenance Director said he was the only Maintenance staff in the facility and was responsible for checking the hot water temperatures on each Unit once weekly. The Maintenance Director said the shower heads in the shower rooms had built-in temperature gauges that displayed the hot water temperatures and the shower rooms contained signage that indicated what the water temperature should be when providing a shower to the residents. The Maintenance Director said the hot water temperature should not exceed 120 F and that the staff providing the showers to residents should not turn the water temperature dial all the way up. The Maintenance Director said the hot water boosters recently installed were specific to the dishwasher in the kitchen and were not related to the water temperatures on the resident units. During an interview on 1/30/26 at 7:48 A.M., the Activities Director (AD) said the Resident Council members said there were times when they would take a shower, but the water was not hot enough, and there were times when the water got too hot. It was random, but enough to take notice. The AD said the Resident Council members discussed concerns for water temperatures a couple of times since the end of October 2025. On 1/30/26 the surveyor observed the Maintenance Director perform the following hot water temperature checks: *Shower Room on the South One Unit at 1:34 P.M.: -The signage on the wall indicated that the water temperature should be checked prior to giving a shower to residents and if the water temperature was greater than 110 F the resident should not receive a shower and the temperature should be reported immediately. -The shower head's built-in temperature gauge indicated a hot water temperature of 69 F, when the manual thermometer used by the Maintenance Director indicated a hot water temperature of 121.1 F. *Shower Room on the South Two Unit at 1:43 P.M.: -The signage on the wall also indicated that the water temperature should be checked prior to giving a shower to residents and if the water temperature was greater than 110 F the resident should not receive a shower and the temperature should be reported immediately. -There was no evidence that the shower head had a built-in temperature gauge. -There was no evidence that a manual thermometer was available for use by staff to check the hot water temperature when prior to showering residents. *Resident #20's bathroom sink at 2:03 P.M.:-The manual thermometer indicated a hot water temperature of 134.6 F. During an interview on 1/30/26 at 3:18 P.M., Certified Nurses Aide (CNA) #7 said the hot water got really hot and then cold, and it was hard to regulate the water temperatures at times. On 1/30/26 at 3:20 P.M., the surveyor observed the shower head's built-in temperature gauge indicated a hot water temperature of 140 F in the shower room on the East One Unit. During an interview on 1/30/26 at 3:25 P.M., CNA #6 said the showers got too hot at times. CNA #6 said the shower on the East Two Unit was hot and it was hard to control the water temperature. During an interview on 1/30/26 at 3:50 P.M., the Administrator said he believed the water temperature should be at 120 F. The Administrator said hearing of the surveyors' observations of hot water temperatures in the shower rooms in the facility, he had a concern for residents' safety. On 1/30/26, the surveyor observed the following hot water temperature checks performed by the Administrator: -Shower room on the East Two Unit at 4:30 P.M.: The manual hot water temperature indicated 126 F. -Shower room on the South Two Unit at 4:40 P.M.: The manual hot water temperature indicated 131 F. During an interview on 1/30/26 at 4:58 P.M., Resident #20 said the water in his/her bathroom sink could be boiling hot at times. Resident #20 said when the water was hot, he/she couldn't touch it because it would almost burn you. Resident #20 said the water in the bathroom sink would get very hot every two or three weeks. During a follow-up interview on 2/2/26 at 11:17 A.M., the Maintenance Director said water temperature checks were performed at random times during the day with no specific rotation. The Maintenance Director said he checked the water temperature in one room per Unit per week. The Maintenance Director said the rooms checked could include a kitchenette, resident room or staff bathroom. The Maintenance Director said he typically did not check the water temperature in the shower rooms because the shower heads had built-in temperature gauges.

Based on observation, interview, and record review, facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#52) out a total sample of 24 residents. Specifically, for Resident #52, the facility failed to ensure:-oxygen tubing and nebulizer equipment changes were completed timely as required.-that the Resident's oxygen and nebulizer equipment and BiPAP (Bilevel Positive Airway Pressure) mask were maintained in a clean and sanitary manner and appropriately stored when not in use to prevent contamination and the spread of infections. Findings Include: Review of the facility policy titled Oxygen Administration, dated 4/9/25 included but was not limited to: >Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. >Keep delivery devices covered in plastic bag when not in use. Review of the facility policy titled Nebulizer Therapy, revised 4/9/25, included but was not limited to: >Change nebulizer tubing weekly. >Store the nebulizer cup and mouthpiece in a zip lock bag. Review of the facility policy titled CPAP/BiPAP cleaning, dated 11/6/25, included but was not limited to: >Clean mask daily . or soap and water. Cover with plastic bag .when not in use. Resident #52 was admitted to the facility in June 2023 with diagnoses including Acute on Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), and Pneumonia. Review of the Person-Centered Care Plan, initiated 6/20/23 and revised 9/23/25, indicated: -has altered respiratory status/difficulty breathing related to COPD, Sleep Apnea, oxygen (O2) dependence with interventions including Bilevel Positive Airway Pressure (BiPAP- noninvasive ventilation device that assists with breathing) as ordered and medications as ordered. -required oxygen therapy related to impaired gas exchange and COPD with interventions including medications as ordered, BiPAP as ordered, and oxygen as ordered. Review of Resident #52's January 2026 Physician's orders indicated: -Oxygen 1 L (liter)/Min via nasal cannula (NC) every shift (11:00 P.M.- 7:00 A.M., 7:00A.M.- 3:00 P.M., 3:00 P.M.- 11:00 P.M.), effective 12/30/24. -Ipratropium/Albuterol Solution 0.5/2.5 (3) milligram (mg)/3 milliliter (ml), 1 vial inhale orally every 6 hours as needed for wheezing, effective 12/20/25.-Apply BiPAP during hours of rest and bedtime with oxygen attached, per home settings, every shift, effective 8/27/25. -Change and date oxygen tubing weekly, every Saturday, night shift (11:00 P.M.- 7:00 A.M.), effective 7/6/24. Review of the Minimum Data Set (MDS) Assessment, dated 12/23/25 indicated Resident #52: -has oxygen therapy and non-invasive ventilator (BiPAP). -has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of a total possible score of 15. Review of the Resident's active Medication Administration Record (MAR) included that the Resident #52 was administered:-Ipratropium/Albuterol Solution 0.5/2.5 (3) milligram (mg)/3 milliliter ml) medication via nebulizer on 1/19/26 at 18:24 P.M. and 1/27/26 at 9:15 A.M. On 1/27/26 at 10:10 A.M., the surveyor observed Resident #52 seated in a wheelchair at his/her bedside with oxygen in use via nasal cannula at 1 L/Min from an oxygen concentrator. The surveyor observed the nasal cannula tubing was dated 1/17/26. The surveyor observed an uncovered nebulizer mask with connecting tubing dated 1/17/26 on the Resident's nightstand that was in contact with an uncovered urinal containing yellow liquid. The surveyor also observed an uncovered, unbagged BiPAP mask covered with a dried white substance also laying on the nightstand surface. On 1/28/26 at 8:22 A.M., the surveyor observed Resident #52 seated at his/her bedside with oxygen tubing/ nasal cannula connected to his/her nose, dated 1/17/26. The surveyor also observed the Resident's nebulizer mask, dated1/17/26, was uncovered and the BiPAP mask covered with a dried white substance were laying on the Resident's nightstand surface. During an interview at the time, Resident #52 said he/she used the oxygen, nebulizer, and BiPAP every day but was unaware of how often the tubing should be changed. During an interview on 1/28/26 at 8:24 A.M., Nurse #8 said she was assigned to Resident #52. Nurse #8 said that Resident #52 was dependent on staff for oxygen, nebulizer, and BiPAP care. Nurse #8 said Resident #52 received oxygen at all times, last received nebulizer medication on 1/19/26 and wore the BiPAP every night. Nurse #8 said Resident #52 was ordered for weekly tubing changes to the oxygen and nebulizer which was done by the night (11:00 P.M.- 7:00 A.M.) shift Nurses. The surveyor and Nurse #8 observed Resident #52's Treatment Administration Record (TAR) which indicated the night Nurse had changed the oxygen tubing on 1/24/26. The surveyor and Nurse #8 observed the Resident sitting at his/her bedside and Nurse #8 said that the Resident's oxygen and nebulizer tubing were dated 1/17/26 and must not have been changed as indicated on 1/24/26. The surveyor and Nurse #8 observed the Resident's nightstand and Nurse #8 said that the BiPAP mask did not appear to have been cleaned after the last use as evident by the coating of white substance on the mask and that both the nebulizer and BiPAP masks were uncovered and making contact with the nightstand surface but should have been in a plastic storage bag to prevent the spread of germs. Nurse #8 said that Resident #52 was at higher risk for pneumonia because of the COPD diagnosis. During an interview on 1/28/26 at 4:24 P.M., the Infection Preventionist (IP) said Resident #52's oxygen and nebulizer tubing should be changed weekly and kept in a plastic storage bag when not in use. The IP said that the Resident's BiPAP masks should be cleaned with soap and water by the Nurse each day and then kept in a plastic storage bag when not in use. The IP said that Resident #52 could be at risk for infection due to the outdated and uncovered tubing and masks. During an interview on 2/2/26 at 12:00 P.M., the Director of Nursing (DON) said oxygen and nebulizer tubing should be changed weekly by the night Nurse as well as nebulizer and BiPAP cleaned after each use. The DON said a dirty mask and the tubing not being changed weekly could contain microbial growth and could result in Resident #52 getting redness/irritation to the skin or an infection.

Based on observations, interviews, and record review, the facility failed to provide sufficient nursing staff for three Resident's (#121, #108, and #109) on two Units (East Two and South Two) out of four total resident units, to maintain the safety and well-being of the resident population. Specifically, the facility failed to provide sufficient nursing staff: 1.for two shifts on the East Two Unit over two consecutive days (1/27/26 and 1/28/26): a. when no staff were in attendance in the Unit Dining Room on the 1/27/26 evening (3:00 P.M. through 11:00 P.M.) shift and a resident seated next to Resident #121 placed fish sticks and tater tots, which were not pureed, in front of Resident #121 who required a pureed diet, increasing the risk of Resident #121 eating the non-pureed food items and choking with no staff present to intervene. b. which increased Resident #108's risk for alteration in skin integrity when the Resident was dependent on facility staff for repositioning and incontinence care, and repositioning and incontinence care was not provided for the Resident on 1/28/26 over a 4.25-hour period during the day (7:00 A.M. through 3:00 P.M.) shift. 2. to provide incontinence care during the day shift on the South Two Unit on 1/28/26 when Resident #109 requested staff assistance after experiencing bowel and bladder incontinence and was subjected to waiting over 30 minutes for staff assistance, increasing the Resident's risk for alteration in skin integrity, infection, and psychosocial harm. Findings include: Review of the facility's policy titled Nursing Services and Sufficient Staff, dated 2/5/25, indicated the following: -It is the policy of this facility to provide sufficient staff . to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. -The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. -Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Review of the facility's policy titled ADLs (activities of daily living), dated 3/1/19 and reviewed and revised 12/1/25, indicated the following: -Care and services will be provided for the following ADLs: -Bathing, dressing, grooming, and oral care. -Transfer and ambulation. -Toileting. -Eating to include meals . -A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy titled Incontinence, dated 11/25/25, indicated that residents that are incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1a. Resident #121 was admitted to the facility in May 2023 with diagnoses including Dementia, abnormal weight loss, and mild protein calorie malnutrition. Review of Resident #121's active Physician orders, dated 9/2/25, no end date, indicated the Resident required a pureed diet texture. Review of Resident #121's active Care Plan indicated: -required assistance of one staff for eating (initiated 7/1/23, revised 2/26/25). -has oral/dental health problems and did not consistently wear his/her dentures (initiated 5/16/23, revised 2/26/25). -Diet as ordered (initiated 5/16/23). During an interview on 1/27/26 at 4:22 P.M., Resident #121's Representative (RR #1) said he/she was concerned for staffing sufficiency on the East Two Unit. RR #1 said the East Two Unit could house 24 residents and that there was currently only one Certified Nurses Aide (CNA) working on the unit at that time. RR #1 said one CNA for 24 residents occurred often on the evening shift on the East Two Unit. RR #1 said he/she visits the facility often and has observed residents wait for up to 20 minutes for assistance from staff to eat. RR #1 said that he/she has spoken with administration within the last couple of months relative to his/her concern for sufficient nursing staff on the East Two Unit and the nursing staffing has not improved. On 1/27/26 at 4:28 P.M., the surveyor observed the following on the East Two Unit: -There was one CNA (#1) working on the Unit. -There was one Nurse (#4) standing at the medication cart next to the nurses' station. -There was one Nurse (#3) seated at the nurses' station using the computer. During an interview with Nurse #3, CNA #1, and Nurse #4 at the time, Nurse #3 said she worked the day shift today (1/27/26) and stayed beyond her scheduled shift to complete required documentation for residents she cared for during the day shift. Nurse #3 said there were 23 residents currently residing on the East Two Unit. CNA #1 said there were supposed to be two CNAs working on the Unit for the evening shift and that she was the only CNA working at the time. CNA #1 said that CNA #8 was supposed to come into work at 3:00 P.M., but CNA #8 had not yet arrived. CNA #1 said no additional staff had been sent to the East Two Unit in the absence of CNA #8. CNA #1 said that working as the only CNA on the Unit from 3:00 P.M. until anytime between 3:30 P.M. and 4:00 P.M., and sometimes later than 4:00 P.M. occurred frequently. CNA #1 said several residents on the Unit required the assistance of two staff for ADL care and transfers and that she could not provide care to those residents without assistance from additional staff member. Nurse #4 said she would typically provide assistance to the CNA when there was one CNA working on the Unit, but that a new admission had just arrived and she needed to complete the new admission tasks for that resident. Review of the 1/27/26 timecards for the East Two Unit indicated: -CNA #1 punched in for the evening shift at 2:55 P.M. -The two CNAs who had worked the day shift had punched out at 3:10 P.M. -CNA #8 punched in at 4:49 P.M. (one hour and 49 minutes after the start of the shift and one hour and 39 minutes after the last day shift CNA punched out). On 1/27/26 between 5:10 P.M. and 5:28 P.M., the surveyor observed the following on the East Two Unit: -Eight residents, including Resident #121, were seated in the dining room. -The evening meal cart had been delivered to the Unit. -At 5:18 P.M., six of eight residents in the Dining Room had been served their meals and were eating. Resident #121's meal had not been delivered, and no staff were present in the Dining Room at the time. -two fish sticks and three tater tots that had been placed directly on the table in front of Resident #121. No staff were present in the Dining Room at this time. At this time, a resident seated next to resident #121 said he/she had given some of his/her fish sticks and tater tots to Resident #121 because Resident #121 didn't have any food. The resident seated next to Resident #121 said, Don't you think [he/she] looks hungry? -One of the six residents eating reached out, touched, and pressed down on another resident's tater tot that was on their plate. No staff were present in the Dining Room at this time. -Activities Aide (AA) #1 and CNA #1 entered and exited the Dining Room intermittently and no staff were observed remaining in the Dining Room until approximately 5:25 P.M., when AA #1 entered and stayed in the Dining Room with the residents. -At this time, CNA #1 and an additional staff member also entered and remained in the Dining Room. -The additional staff member removed the fish sticks and tater tots from in front of Resident #121, following the surveyor's inquiry whether the food items were meant for Resident #121's consumption. -CNA #1 then brought a meal tray containing pureed food to Resident #121. During an interview at 5:30 P.M., Nurse #4 said that a staff member should stay in the Dining Room to supervise residents while they were eating. On 1/28/26 at 9:13 A.M., the surveyor observed the following in the East Two Unit Dining Room: -CNA #3 was assisting Resident #121 to eat breakfast by loading the Resident's utensil and bringing the utensil to the Resident's mouth. -At one time during the meal, Resident #121 was able to reach forward and grasp CNA #3's hand that held the loaded utensil and guide the utensil and CNA #3's hand to his/her mouth. During an interview on 1/29/26 at 3:42 P.M., the Speech-Language Pathologist (SLP) said residents are typically prescribed pureed diets after trialing less restrictive diets and that the pureed diets are provided for residents who cannot adequately chew or manipulate less restrictive food textures in their mouths. The SLP said a resident who has been prescribed a pureed diet should not have fish sticks and tater tots due to the risk for choking and development of aspiration pneumonia. The SLP said it was scary to think that the Dining Room on the East Two Unit would be unsupervised during meals as residents may consume the wrong diet texture. 1b. Resident #108 was admitted to the facility in April 2022 with diagnoses including Acute Kidney Failure, Diverticulitis, Cognitive Impairment, Obesity, and Need for Assistance with Personal Care. Review of Resident #108's active Physician orders, dated 11/21/24, no end date, indicated: Resident to be pair care (two staff members) until further notice, dated 11/21/24, no end date. Review of Resident #108's active Care Plan indicated: -The Resident was incontinent of bowel and bladder related to Dementia. -The Resident had an ADL deficit and was dependent on two staff members for bathing, dressing, bed mobility, and personal hygiene. -Clean peri-area with each incontinent episode. -The Resident was at risk for potential skin impairment due to impaired mobility, impaired safety, impaired judgment, obesity, and incontinence. -Keep skin clean and dry. On 1/28/26 between 7:45 A.M. and 11:49 A.M., the surveyor observed the following in the East Two Unit Dining Room: -Resident #108 was seated in the East Two Unit Dining Room, in his/her wheelchair. -At 8:35 A.M., Resident #108's Representative (RR #2) approached the surveyor in the East Two Dining Room and said: -that he/she came in daily in the mornings and sometimes in the afternoons to attend activities with Resident #108. -RR #2 said he/she thought the nursing staff on the Unit were good and worked hard, but that they needed more staff. -RR #2 said he/she thinks Resident #108 sits in his/her wheelchair for the whole day without receiving incontinent care because there are not enough staff. -RR #2 said Resident #108 will sometimes sit in his/her wheelchair from 7:00 A.M. through 2:00 P.M. without moving. -RR #2 said Resident #108 was incontinent and was dependent on nursing staff to return the Resident to bed to perform incontinent care. -RR #2 said that he/she has brought his/her concerns for sufficient staffing up at Resident #108's care plan meetings and that the facility's response has been that the facility has enough staff. -At 8:43 A.M., RR #2 assisted with cutting up Resident #108's breakfast meal and assisted the Resident to eat. -Resident #108 was provided with a large cup of liquids at 10:15 A.M. and 11:29 A.M. and the Resident consumed both cups of liquids. -The surveyor did not observe between 7:45 A.M. and 11:49 A.M., any staff offer the following to Resident #108: -assistance for repositioning. -check for whether the Resident was incontinent. -Incontinence care. During an interview on 1/29/26 at 9:55 A.M., CNA #2 said she was usually responsible to provide care for 12 to 13 residents on the day shift and that two CNAs were always scheduled for the day shift on the East Two Unit. CNA #2 said there were three CNAs scheduled today and that she did not know why, but that having three CNAs was helpful for providing care to the residents. CNA #2 said Resident #108 was always incontinent of bowel and bladder and that the Resident never used a toilet. CNA #2 said to provide Resident #108 with incontinence care on the day shift, she would have another staff member assist her with getting the Resident back to bed using a mechanical lift. CNA #2 said Resident #108 was usually on her assignment and that Resident #108 was on her assignment on 1/28/26. CNA #2 said there were usually two CNAs to care for all of the residents on the Unit, so there was not enough time to provide rounds for incontinence care on the Unit until after lunch. CNA #2 said she did perform incontinence care rounds for some residents after lunch when she worked, but she did not usually perform incontinence care any time for Resident #108 after getting him/her out of bed unless the Resident had a bowel movement. CNA #2 said she was just one CNA for 12 residents, and all morning ADL care was required to be completed before lunch time. CNA #2 said Resident #108 did not usually receive incontinence care after getting out of bed in the morning until the evening (3-11) shift. CNA #2 said she did not provide any incontinence care to Resident #108 during the day shift after she assisted the Resident out of bed in the morning on 1/28/26. During an interview on 1/29/26 at 10:11 A.M., Nurse #2 said that incontinence rounds and repositioning were to be completed by the CNAs approximately every two hours for residents on the Unit. Nurse #2 said that Resident #108 was incontinent of bowel and bladder and should be included in the residents who required incontinence care and assistance with repositioning. Nurse #2 said she worked on the East Two Unit during the day shift on 1/28/26 and that she was not aware Resident #108 had not been repositioned and provided with incontinence care anytime between 7:45 A.M. and 11:49 A.M. Nurse #2 said that she would have to look into what happened because Resident #108 should have been repositioned and provided with incontinence care. Nurse #2 said repositioning and incontinence care was important for Resident #108 to help reduce the Resident's risks for skin breakdown and infection. During an interview on 1/29/26 at 11:51 A.M., the Scheduler said she was told when first working at the facility that the East Two Unit was always to be scheduled for two CNAs on the day and evening shifts unless approval for an additional staff member to serve as a one to one for a resident with safety concerns was provided. During an interview on 1/29/26 at 2:50 P.M., with the Director of Nursing (DON) and the Assistant Director of Nurses (ADON), the DON said staffing was determined based on the facility's census and that resident acuity was considered. The DON said the East Two Unit was always scheduled with two CNAs on the day and evening shifts and that a third CNA could be moved to the Unit if resident behaviors occurred and one to one care was needed for a resident. The ADON said there should always be a staff member in the East Two Unit Dining Room if residents are in the room, eating, and require supervision. The ADON said the risk for not having a supervising staff member in the East Two Unit Dining Room on 1/27/26 was that the Resident could have choked if he/she had consumed the fish sticks and tater tots that were placed in front of him/her by another resident. The ADON said the risks for staff not providing repositioning and incontinence care for Resident #108 between 7:45 A.M. and 11:49 P.M. on 1/28/26 were skin breakdown and infection. 2. Resident #109 admitted to the facility in August 2024, with diagnoses including malignant neoplasm of the brain, severe obesity, malignant neoplasm of the kidney, anxiety disorder, depression, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #109: -was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15 points. -did not exhibit behaviors of rejection of care. -was dependent on staff for toileting hygiene. -was always incontinent of bladder. -was always incontinent of bowel. -was not on a bowel toileting program used to manage his/her bowel continence. Review of Resident #109's Bowel and Bladder Care Plan, initiated 8/26/24, indicated but was not limited to the following: -The Resident was incontinent of bladder and bowel related to physical limitations. -Goal: The Resident would remain free from skin breakdown due to incontinence and brief use. -Interventions: Clean peri-area with each incontinence episode. Monitor for signs and symptoms of urinary tract infection. On 1/28/26 at 7:32 A.M., on the South Two Unit, the surveyor observed Nurse #7 make a phone call to ask that CNA #4 come to the South Two Unit, stating that the unit was waiting for her. During a medication pass observation on 1/28/26, the surveyor observed the following: -At 7:40 A.M., Resident #109 told Nurse #7 that he/she needed to be changed. -At 7:41 A.M., Nurse #7 made a phone call, and said that she had called three times to ask that CNA #4 come to the South Two Unit and noted that the Unit really needed CNA #4. -At 7:44 A.M., CNA #4 arrived on the South Two Unit. On 1/28/26, the surveyor observed the following on the South Two Unit: -A CNA walked by Resident #109's room where the call light was on at 8:01 A.M., 8:03 A.M., and 8:04 A.M., and did not respond to the call light. -At 8:04 A.M., Resident #109's call light remained on. During an interview at the time, Resident #109 said that he/she needed to be changed. Resident #109 said that staff had not yet assisted him/her since he/she told Nurse #7 he/she needed incontinence care. -At 8:07 A.M., CNA #5 entered Resident #109's room, turned off the call light, and exited the Resident's room. During an interview at the time, CNA #5 said Resident #109 needed to be changed and the Resident required two staff to assist him/her with changing. CNA #5 said the other two CNAs were busy and the Resident would need to wait to be changed until CNA #5 could receive staff assistance. -At 8:17 A.M., two CNAs entered Resident #109's room to provide him/her with assistance. (37 minutes after Resident #109 informed Nurse #7 that he/she needed to be changed). Review of the Daily Schedule Report for 1/28/26 indicated that three CNAs were scheduled to work on the South Two Unit for the 7:00 A.M. - 3:00 P.M. shift on 1/28/26. During an interview on 1/30/26 at 9:35 A.M., Resident #109 said it made him/her feel awful when he/she had to wait more than 30 minutes on the morning of 1/28/26 to receive incontinence care. Resident #109 said he/she was prone to urinary tract infections. During an interview on 1/30/26 at 9:37 A.M., CNA #5 said there were three CNAs scheduled to work on the South Two Unit the morning of 1/28/26. CNA #5 said the CNAs were busy the morning of 1/28/26 when Resident #109 needed assistance with incontinence care. CNA #5 said she and another CNA assisted the Resident once another CNA was available to assist. CNA #5 said the CNAs provided Resident #109 with a bed bath and incontinence care. CNA #5 said that Resident #109 had been incontinent of bowel and bladder at the time. During an interview on 1/30/26 at 9:45 A.M., Nurse #7 said on the morning of 1/28/26 there was an issue with staffing on the South Two Unit, that there were only two CNAs on the unit and there should have been three CNAs. Nurse #7 said she called the Staffing Coordinator and informed her that there were only two CNAs on the Unit. Nurse #7 said that Resident #109 was always incontinent of bowel and bladder and required two staff to assist with incontinence care. Nurse #7 said her expectation was that residents would not have to wait to receive assistance and would receive assistance as soon as staff were available to assist them. During an interview on 1/30/26 at 10:22 A.M., the Staffing Coordinator said that the Units were fully staffed the morning of 1/28/26. The Staffing Coordinator said that Nurse #7 had called her and informed her that one CNA was missing on the South Two Unit. The Staffing Coordinator said that she located CNA #4 on the South One Unit and instructed her to report to the South Two Unit. The Staffing Coordinator said she did not notify her supervisor of the issue. During an interview on 1/30/26 at 11:03 A.M., CNA #4 said she believed she was assigned to the South One Unit the morning of 1/28/26. CNA #4 said she was informed by the Nurse on the South One Unit that she needed to report to the South Two Unit. CNA #4 said she believed it was around 8:00 A.M. that she was instructed to report to the South Two Unit. During an interview on 1/30/26 at 11:19 A.M., the DON said he was notified the morning of 1/28/26 that there was a staffing issue on the South Two Unit. The DON said the South Two Unit required three CNAs at that time. The DON said his expectation was that staff inform him when assistance was needed to address residents' needs. The DON said he thought that waiting over 30 minutes was too long for Resident #109 to wait to receive assistance.

Based on observation, interviews, and records reviewed, the facility failed to coordinate an assessment with the PASARR program (screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for two Residents (#7 and #11), of two applicable residents reviewed for PASARR, out of a total sample of 24 residents. Specifically, the facility failed to:1.For Resident #7, refer to the PASARR Office for a Level II Resident Review in a timely manner when the Resident: -Experienced suicidal remarks and an attempt to self-harm. -Required immediate transfer to the hospital for medical and psychiatric evaluation.2.For Resident #11, refer the Resident to the PASARR Office for Resident Review after the Resident experienced a significant change in status requiring psychiatric hospitalization. Findings Include:Review of the facility policy titled Resident Assessment-Coordination with PASARR Program, last revised on 9/21/25, included but limited to:*This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.-All applicants to this facility will be screened for serious mental disorder or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.-PASARR Level I - initial pre-screening that is completed prior to admission.>Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.>Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. -PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. -The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.-Recommendations, such as any specialized services, from a PASARR Level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. -Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include:>A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).>A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.>A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. 1.Resident #7 was admitted to the facility in May 2025, with diagnoses including Mood Disturbance, Anxiety Disorder, Depression, Unspecified Mood Affective Disorder, and Unspecified Dementia with Other Behavioral Disturbance. Review of the Level I PASARR, dated 11/19/25, indicated Resident #7:-had documented diagnosis of a mental illness or disorder (MI/D)-had substance use disorder (SUD) that may lead to chronic disability-Question Number Six was completed with an answer of Yes indicating currently or within the past six months, the Resident has had limitation in major life activities.(adaptation to change) or may be due to mental illness or disorder (MI/D). -If the answer to Question Number Six was Yes, check Positive SMI screen. Otherwise, check Negative SMI screen. -Positive SMI was checked. Next step, complete section C-Section C not completed Review of the Physician Progress Note, dated 11/5/25, indicated Resident #7: -had suicidal remarks and self-harm attempt.-threatened to wrap a call bell wire around his/her neck. -expressed intent to his/her daughter to drive a car into a wall. -unplugged his/her roommate's oxygen tank and attempted to wrap the Oxygen tubing around his/her neck.-arrange immediate transfer to the hospital for medical and psychiatric evaluation. Review of the Physician Progress Note, dated 11/19/25, indicated Resident #7: -was assessed by the Physician for a follow-up depression. -had mood disorder, seen for worsening depression. -was noted to be more withdrawn.-was seen by Behavioral Health with recommended to increase their prescribed anti-depressant Sertraline to 75 milligrams (mg) from 50 mg daily. -nursing notes that the Resident was scratching at his/her upper arms, with no known irritants. Review of the clinical record indicated Resident #7: -was hospitalized from [DATE] to 11/6/25 for inpatient psychiatric care. -was started on Lorazepam 0.5 mg (anti-anxiety medication) every 6 hours as needed (PRN), initiated on 11/6/25 after hospitalization. -returned to the facility on [DATE]. -had no evidence that the Resident had been referred to the PASARR program after the hospitalization. Review of Resident #7's November 2025 Medication Administration Record (MAR) indicated:-Ativan Oral Tablet 0.5 milligrams (mg) (Lorazepam) give 0.5 mg by mouth every 6 hours as needed (PRN) for anxiety/agitation x 14 days, initiated 11/6/25. Further review of Resident #7's November 2025 MAR indicated medication had not been administered to the Resident. Review of the Minimum Data Set (MDS) Assessment, dated 11/12/25, indicated Resident #7: -was able to make him/herself understood, and he/she usually understood others with clear comprehension. -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of 15 total possible points. -active diagnoses included depression and anxiety. Review of Resident #7's clinical record on 1/30/26 failed to indicate any evidence that the Resident had been referred to the PASRR program when he/she experienced a significant change in mental status, immediate transfer to the hospital for medical and psychiatric evaluation and required the use of anti-anxiety medication. During an interview on 1/30/26 at 12:25 P.M., the Social Worker (SW) #1 said that a Level II had not been completed for Resident #7 and it should have been. SW #1 said that Resident #7 was sent out for mental status change for suicidal remarks and an attempt to self-harm back in November 2025 and a PASARR Level II should have been completed. 2. Resident #11 was admitted to the facility in May 2016 with diagnoses including Depression, Psychotic Disorder, and Dementia. Review of Resident #11's Minimum Data Set (MDS) Assessment, dated 4/4/24, indicated the following: -The Resident usually made him/herself understood and usually understood others. -The Resident had active diagnoses including Dementia, Psychotic Disorder, and Depression. -The Resident had no signs of delirium during the MDS observation period. -The Resident had no indications for psychosis during the MDS observation period. -The Resident did not demonstrate wandering behavior during the MDS observation period. Review of Resident #11's Nurse Health Status Note, dated 5/25/24, indicated the following: -Facility staff discovered that the Resident had been walking up the street from the facility at a local gas station. -The Resident was transferred to the hospital and was admitted to the psychiatric ward. Review of Resident #11's Hospital Emergency Department (ED) Note, dated 5/25/24, indicated the following: -The Resident presented in the ED for evaluation of erratic behavior. -The Resident had increasing behaviors over several previous months while at the facility, including refusal of taking psychiatric medications and exit seeking. -The plan was to admit the Resident to the GPU (Geriatric Psychiatry Unit). Review of Resident #11's Hospital Discharge summary, dated [DATE], indicated the following: -The Resident was being discharged back to the facility. -Discharge diagnoses included Schizoaffective Disorder, Bipolar type. Review of Resident #11's clinical record failed to indicate any evidence a PASRR had been completed for Resident Review and communicated to the PASRR Office any time after the Resident had been hospitalized at the GPU. During an interview on 1/28/26 at 1:20 P.M., the Social Worker (SW) said she reviewed Resident #11's clinical record and located no evidence a PASRR had been completed for Resident Review following the Resident's GPU admission in May 2024. The SW said she also called the PASRR Office and the PASRR Office reported no history of communication from the facility following the Resident's GPU admission. The SW said a PASRR should have been completed and submitted to the PASRR Office for Resident Review due to the Resident having had a significant change in condition requiring psychiatric hospitalization and that this had not been done.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) documentation related to positioning was either incomplete and/or inaccurate.Findings include:Review of the Facility policy titled, Documentation in Medical Record, revised January 2025, indicated the following:-Staff shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. -Documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care. Resident #1 was admitted to the Facility July 2025, with diagnoses including but not limited to; cerebral infarct (blood clot blocks an artery in the brain, cutting off blood flow to a specific area), end-stage kidney disease, and pressure ulcers.Review of Resident #1's Minimum Data Set (MDS) admission Assessment, dated 08/05/25, indicated he/she was dependent on staff assistance for bed positioning.Review of Resident #1's ADL Flow Sheet (CNA documentation) dated 08/01/25 through 08/14/25 indicated for the following shifts, documentation was inaccurate or incomplete for positioning:-08/02/25 at 6:00 A.M, 10:00 A.M., 12:00 P.M., and 2:00 P.M. left blank.-08/03/25 at 8:00 A.M, 10:00 A.M., and 2:00 P.M. documented NA (not applicable).-08/05/25 at 6:00 A.M., left blank, 10:00 A.M., 12:00 P.M., and 2:00 P.M. documented NA.-08/08/25 at 8:00 A.M. and 10:00 A.M. documented NA.-08/10/25 at 10:00 A.M. documented NA.During an interview on 09/09/25 at 4:00 P.M., the Director of Nursing (DON) said the CNA assigned the resident is responsible for completing the CNA flow sheet. The DON said the CNA flow sheet documentation on 08/02/25, 08/03/25, 08/05/25, 08/09/25 and 08/10/25 should not be blank or documented as NA. The DON said Resident #1's CNA flow sheet was not complete or accurate.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control practice standards in the facility laundry room and for three Resident (#18, #23, and #5) out of a total sample of 23 residents. Specifically, facility staff failed to: 1. In the facility's clean laundry room, store clean mechanical lift (assistive device that allows people whose mobility is limited to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) slings (fabric portion of a mechanical lift system that comes into direct contact with the person and supports their weight during transfers) and clean bath linens in a manner to reduce the risk for contamination by dust and debris. 2. For Resident #18, adhere to requirements relative to Enhanced Barrier Precautions (EBP: infection control measures that involve gown and glove use during high-contact resident care activities) for Resident #18 when the Resident had a pressure ulcer (PU: injury to the skin and the tissue below the skin due to pressure ) and ileostomy (surgical opening in the belly [abdominal wall] for stool to leave the body), increasing the Resident's risk for infection. 3. Position Resident #23's indwelling catheter tubing off the floor, increasing the Resident's risk for infection. 4. For Resident #5 ensure that Contact Precautions (type of TBP used to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or patient environment) were implemented when the Resident was suspected to have Scabies (parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) infection increasing the risk of potential transmission to other residents. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Healthcare-Associated Infections (HAIs), Appendix D - Linen and Laundry Management, Best Practices for Management of Clean Linen, dated 3/19/24, indicated: Sort, . and store clean linens in a manner that prevents risk of contamination by dust, debris, . On 10/17/24 at 2:30 P.M., the surveyor observed the following in the facility laundry's clean linen room: -One large plastic barrel with a heaping number of mechanical lift slings piled approximately 12 inches higher than the top of the barrel. -Several mechanical lift slings were hanging over the sides of the barrel and the sling straps were on the floor. -that the floor in the clean linen room had dust and debris (spots of dried brown debris, pieces of torn plastic). -The tops of the washing machines (located in the clean linen room) were covered in dust and dripped, dried white debris. -Dust, dried brown debris, torn pieces of plastic covered in dust, a crumpled paper covered in dust, and one black glove covered in dust, in between the slats of, and under wood pallets next to one washing machine. -Laundry Aide #1 standing at the table in the clean laundry room, folding towels and stacking them on the table. During an interview on 10/17/24 at 2:40 P.M., Laundry Aide #1 said he worked full time at the facility and had worked at the facility for about one year. Laundry Aide #1 said that the mechanical lift slings piled in the barrel were all clean and that staff from resident units would come to the laundry room to retrieve slings as needed for residents in the facility. Laundry Aide #1 said that there was no other place to store the slings and that he had always been told to put them in the barrel. Laundry Aide #1 said that there was dust and debris on the floor in the clean linen room and that there was also dust and debris on the tops and sides of the washing machines. Laundry Aide #1 said that there was no cleaning schedule for the floor or equipment in the clean linen room and that laundry personnel would just clean the area when they noticed the area needed cleaning. Laundry Aide #1 said that he did not know when the clean linen room and its equipment had been cleaned last. During an observation and interview on 10/17/24 at 2:45 P.M., the surveyor observed the clean linen room with the Laundry Supervisor. The Laundry Supervisor said that laundry staff were required to clean the laundry room and that there was no cleaning schedule in place. The Laundry Supervisor said that the mechanical lift slings in the barrel were clean and that the slings touching the floor would be considered contaminated. The Laundry Supervisor also said it was important to keep the floor and equipment clean and free of dust and debris in the clean linen room as this was the room where clean linens were stored before being transported to the resident units. The Laundry Supervisor then said that he did not know when the areas were cleaned last and that he hoped that laundry staff would be able to clean the clean linen room by the upcoming weekend. During an interview on 10/18/24 at 12:15 P.M., the District Manager for Laundry Services said that laundry staff were responsible to maintain the clean linen room in a sanitary manner to reduce the risk for contamination of clean linens. The District Manager for Laundry Services said that the clean mechanical lift slings should have been stored in a manner to ensure they did not come in contact with the floor and that that floor and equipment in the clean linen room should have been free of dust and debris. 42690 2. Review of facility policy titled Enhanced Barrier Precautions, revised August 2024, indicated the following: - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. -High-contact resident care activities include (in part): a. dressing b. bathing c. transferring d. providing hygiene g. Device care or in use: urinary catheters h. Wound care: any skin opening requiring a dressing -Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Resident #18 was admitted to the facility in August 2024, with diagnoses including Ileostomy Status, Pressure ulcer of the sacral Region (bottom of the spine), Pressure ulcer of the left heel, and a local infection of the skin and subcutaneous tissue (just under the skin). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the following in Section H (Bowel and Bladder): -Appliances: --Indwelling catheter --Ostomy (including ileostomy) Review of the Wound Care follow-up Progress Note dated 10/8/24, indicated the following: -Patient is being seen today for evaluation and treatment recommendations regarding pressure ulcers to coccyx, bilateral buttocks, left heel and right elbow. On 10/15/24 at 10:52 A.M., from the hallway outside of Resident #18's room, the surveyor observed the following: -EBP signage hanging on the door frame at the entrance of the Resident's room that indicated for Providers to wear gloves and a gown for high-contact resident care activities. High-Contact activities included: -dressing, transferring, providing hygiene, changing briefs, device care (urinary catheter), wound care (any skin opening that required a dressing). -A three drawer bin containing PPE, that included gloves and gowns. -Resident #18's privacy curtains drawn and voices could be heard from behind the curtains. The surveyor observed CNA #3 exiting the room immediately after the observation on 10/15/24 at 10:52 A.M. The surveyor observed that CNA #3 was not wearing a gown or gloves. When the surveyor asked which of the three residents in the room were on EBP, CNA #3 said that he was not sure which of the three residents in the room were on EBP because he did not usually work on this side of the hallway. When the surveyor asked how CNA #3 would find out which resident in the room required EBP be donned (worn) when providing care, he said that he would have to ask the person he was working with, CNA #2. Immediately following the interview with CNA #3, CNA #2 opened the privacy curtains for Resident #18. When the surveyor asked CNA #2 what kind of care was being provided for Resident #18, CNA #2 said she and CNA #3 provided full body care and should have worn PPE, but just forgot. The surveyor observed that Resident #18 was lying in bed at this time. On 10/15/24 at 10:55 A.M., the surveyor and CNA #2 observed the EBP sign outside of Resident #18's room. CNA #2 said that PPE should be worn when performing the following activities: dressing, bathing, and transfers. The surveyor observed CNA #3 enter the room with a Hoyer lift (a mechanical lift used to transfer a resident from the bed to the wheelchair) and CNA #2 followed behind CNA #3 and closed the door. The surveyor did not observe either CNA #2 or CNA #3 don the appropriate PPE from the PPE cart located outside of the Resident's room, as required. The surveyor observed several minutes later, CNA #2 and CNA #3 exited the room, and Resident #18 could be seen in the room, seated in the wheelchair. The surveyor did not observe CNA #2 or CNA #3 doff (remove) any PPE when they exited the Resident's room. During an interview on 10/16/24 at 8:05 A.M., the Director of Nursing (DON) said that gowns and gloves should have been worn while care was provided for Resident #18 as EBP were in place due to the Resident having wounds, an ileostomy, and a urinary catheter. 50563 3. Review of the facility policy titled Catheter Care, Urinary, dated January 2024, indicated the following: -Infection Control: >Be sure the catheter tubing and drainage bag are kept off the floor. Resident #23 was admitted to the facility in July 2016, with diagnoses including Dementia (the loss of cognitive functioning including thinking, remembering and/or reasoning to such an extent that it interferes with a person's daily life). On 10/15/24 at 9:25 A.M., the surveyor observed Resident #23 seated in his/her wheelchair with the indwelling catheter bag below the wheelchair in a privacy bag. The surveyor observed the privacy bag was laying on the floor. On 10/16/24 at 2:45 P.M., the surveyor observed Resident #23 seated in his/her wheelchair with the indwelling catheter bag positioned below the wheelchair in a privacy bag. The surveyor observed the catheter tubing was intermittently touching the floor. On 10/17/24 at 9:29 A.M., the surveyor observed Resident #23 seated in his/her wheelchair with the indwelling catheter bag positioned below the wheelchair in a privacy bag. The surveyor observed the catheter tubing was laying on the floor. On 10/18/24 at 10:03 A.M., the surveyor and CNA #5 observed Resident #23. CNA #5 said that the indwelling catheter tubing was laying on the floor. CNA #5 further said that the catheter tubing being on the floor was an infection control concern. On 10/18/24 at 12:42 P.M., the surveyor reviewed the observations of the indwelling catheter privacy bag and tubing with Unit Manager (UM) #1. UM #1 said this was an infection control concern. On 10/18/24 at 1:00 P.M., the Director of Nursing (DON) said the expectation is that the indwelling catheter would be kept off the floor. 51466 4. Review of the Massachusetts Department of Public Health (MA DPH) Guidance titled Infection Prevention in Long Term Care Scabies, dated January 2019, included the following: -In addition to Standard Precautions, Contact Precautions should be used for the care of patients infested with scabies until 24 hours after beginning treatment with an appropriate scabicide (medication that kills the itch mite that causes scabies). -Contact Precautions can be discontinued if 24 hours have passed following the application of the scabicide. Review of the facility policy titled Head Lice and Scabies Exposure and Treatment, revised October 2024, indicated: -Residents who contract scabies are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. -Nursing will administer scabies treatment according to manufacturer's instructions. -Staff or residents who may have had potential contact with the affected resident should be assessed for signs of scabies infestation -Staff will follow appropriate transmission-based precautions- including Personal Protective Equipment (PPE), when providing care to the affected resident(s). Resident #5 was admitted to the facility in October 2023, with diagnoses including Respiratory Failure (a serious condition that makes it difficult to breathe on your own that develops when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs and difficulty breathing) Coronary Artery Disease (CAD: heart condition that occurs when fatty deposits of plaque build up in the coronary arteries causing them to narrow and restrict blood flow to the heart), and Dementia. Review of the Minimum Data Set (MDS) Assessment, dated 10/4/24, indicated Resident #5 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15, and required partial to moderate assistance with activities of daily living (ADLS: basic tasks like bathing, dressing and eating). Review of the Resident #5's clinical record included the following: -Nursing Progress Note, dated 10/8/24, indicated the Resident was complaining of being very itchy and was observed to have a raised rash on his/her bilateral (both) hands. The Nurse requested the Wound Team assess the areas, and an outside appointment was made with Dermatology for 2:00 P.M. that day. -Wound Consultation Note, dated 10/8/24, indicated the Resident had an evaluation for scabies rash on his/her abdomen, chest, neck, hands, and bilateral legs. The areas had linear indurated (thickening and hardening of the skin in a line pattern) rash with erythema (redness) and itchiness that worsened at night. -Nurse Practitioner (NP) Progress Note, dated 10/9/24, (late entry for 10/8/24), indicated the Resident presented with a rash and intermittent itchiness to his/her arms, neck and right leg. There was concern for scabies and it was recommended that the Resident be seen by Dermatology for definitive diagnosis and for the facility to maintain precautions. -Dermatology Consult, dated 10/8/24, indicated the Dermatologist was unable to determine if scabies was present, but recommended treatment for scabies which included Permethrin Cream (scabicide) and Triamcinolone Cream (topical corticosteroid cream used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions). Review of the October 2024 Physician's Orders, indicated the following order was initiated on 10/8/24 at 4:00 P.M. (upon the Resident's return from the Dermatology Consult): -Permethrin Cream 5% from the neck down, then shower eight hours later and repeat the treatment on 10/18/24-1 week later, for treatment of Scabies, -Triamcinolone Cream 1% two times daily for two weeks, then daily for one month. Review of Administration Record (MAR) for October 2024, indicated the Permethrin Cream for Scabies treatment was administered to Resident #5 on 10/11/24 (3 days after the Dermatology Consult). On 10/15/24 at 10:09 A.M., the surveyor observed Resident #5 in his/her room. The surveyor observed that the Resident had a reddened raised rash with scattered scab-like areas and scratches to the top of his/her right hand and right upper arm. During an interview at the time, the Resident said the rash was from bugs. The surveyor observed the door outside of the Resident's room did not have signage indicating any precautions were in place, but a bin with three drawers which had PPE including gowns and gloves was located outside of the Resident's room. On 10/16/24, the surveyor observed the following: -7:45 A.M., a bin with PPE remained outside of Resident #5's room. There was no visible precautions signage. -8:28 A.M. Housekeeping Staff #1 entered the Resident's room with gloves that were previously worn cleaning other resident's rooms (Housekeeping Staff #1 did not doff, conduct hand hygiene and don new gloves) and hand hygiene was not performed prior to entering the Resident's room. Housekeeping Staff #1 exited the Resident's room shortly after wearing the same gloves, did not perform hand hygiene and proceeded to enter other resident rooms on the Unit. During an interview at 8:31 A.M., Housekeeping Staff #1 said he/she did not know why the PPE bin was outside of the Resident's room, and did not understand the surveyor's questions because he spoke French. -During an interview at 8:44 A.M., the SDC said the PPE bin outside of the Resident's room was for Enhanced Barrier Precautions (EBP: infection control intervention used to reduce the spread of organisms by utilizing PPE during high contact resident care activities). The SDC was observed to speak with Unit Manager (UM) #1 who said the Resident was on EBP related to a wound which had resolved. UM #1 said the PPE bin could be removed after breakfast. -9:04 A.M., Certified Nurses Aide (CNA) #7 said she did not know why Resident #5 had a precaution bin (PPE bin) outside of his/her room. -12:52 P.M., the PPE bin was no longer observed in front of the Resident's room. During an interview on 10/16/24 at 1:35 P.M., CNA #6 said she thought the Resident was on precautions for a respiratory infection. CNA #6 said if a Resident was put on precautions, the Nurse would notify the CNAs and a precaution sign would be posted outside of the room. CNA #6 further said she was not aware of any rashes or skin issues with any of the residents on the unit. During an interview on 10/16/24 at 1:58 P.M., UM #1 said Resident #5 was found to have a rash and was seen by the Wound Consultant for concern of scabies infection. UM #1 said the Resident was sent to a Dermatology appointment on the same day, and it was uncertain what caused the rash, but recommended treatment for scabies at that time. UM #1 said when Resident #5 left for the Dermatology appointment on 10/8/24, facility staff deep cleaned his/her room and performed skin checks on the other residents on the Unit. UM #1 said if a resident presents with a rash, the Nurse will notify the Physician and obtain orders including if precautions are warranted. UM #1 further said scabies could be contagious but would need to further clarify with the Infection Control Nurse because she is not very familiar with scabies and thought it was spread by touch. During an interview on 10/16/24 at 2:00 P.M., Nurse #8 said Resident #5 was treated for scabies and was put on Contact Precautions for 24 hours which started on 10/8/24 and ended on 10/9/24. Nurse #8 said if a Resident was put on Contact Precautions, a Physician's order would be obtained, staff would be made aware of the precautions, a sign is posted outside of the Resident's room and PPE would be used as indicated. The surveyor and Nurse #8 reviewed the Dermatology Consult, dated 10/8/24, and Nurse #8 said it was uncertain if Dermatology confirmed the diagnosis of scabies. Nurse #8 further said the Resident was treated for scabies due to the Dermatology recommendations and the Physician at the facility was in agreement with the recommendation and gave an order for treatment. During an interview on 10/17/24 at 9:42 P.M., the Director of Nursing (DON) said Resident #5 was found to have a rash during wound rounds on 10/8/24. The Wound Consultant felt strongly that it was scabies, so the Resident was put on Contact Precautions at that time. The DON said all items were removed from the Resident's room, including the mattress, and a deep clean was performed on 10/8/24 when he/she left for the Dermatology appointment. The DON said that she was filling in as the temporary Infection Control Nurse, was out of the building for a long weekend after the Resident's Dermatology appointment and the decision to keep the Resident on Contact Precautions would have been left for the Supervisor/ Unit Manager. The DON said was unaware that the precaution bin was still outside of the Resident's room until staff informed her on 10/16/24. The DON said if the Resident was placed on Contact Precautions, signage would be posted outside of the Resident's room to alert all staff that a gown and gloves were required to be worn prior to entering the room. The DON said there should have been a Physician's Order for Contact Precautions and a care plan should have been implemented indicating the rash and Contact Precautions that were in place. During an interview on 10/17/24 at 10: 08 A.M., UM #2 (who was also the Wound Nurse) said a wound assessment was requested for Resident #5 because a staff nurse had noted he/she had an itchy rash. UM #2 said the Resident's rash was evaluated by the Wound Consultant who noted that the Resident had self-inflicted scratches, had verbalized itchy skin, and had a rash on his/her abdomen, forehead, and hands. UM #2 said the Wound Consultant thought the rash could be scabies, a Dermatology appointment was obtained the same day, and the recommendation was made to treat the Resident for scabies. UM #2 said Resident #5 was immediately placed on Contact Precautions, and a PPE bin and signage were placed outside of the Resident's room. UM #2 said a deep cleaning of the Resident's room occurred on 10/8/24, and skin assessments were performed for other residents on the unit. UM #2 said Contact Precautions were put into place for 24 Hours, starting on 10/8/24 and were discontinued on 10/9/24. UM #2 said that the Wound Consultant reassessed the Resident's rash on 10/15/24, and noted scabs were present, but said there were no further complaints of itchiness, and was happy the facility was treating the Resident for scabies. UM #2 said when a resident required Contact Precautions, a Physician's order would be obtained, Nurses would verbally provide report about required precautions to the CNAs, and it would be documented in the Resident's care plan. During a follow-up interview on 10/17/24 at 11:09 A.M., UM #2 said Resident #5 was administered Permethrin Cream (treatment for scabies infection) on 10/11/24 (3 days after the Dermatology appointment). UM #2 said Contact Precautions were initiated on 10/8/24 and discontinued on 10/9/24 (where not in place until 10/12/24 as per the facility policy and MA DPH guidance), that the Resident's room was deep cleaned on 10/8/24 and had not been deep cleaned afterwards. UM #2 said she reviewed the Resident's clinical record and there was no Physician's order obtained for the Contact Precautions. During an interview on 10/17/24 at 1:17 P.M., the surveyor relayed concerns about the facility's infection control process relative to Resident #5 treatment of scabies infection. The DON said she did not know why Contact Precautions were not maintained until 24 hours after the Resident received his/her initial scabies treatment on 10/11/24.

Based on observation, interview, and policy review, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to: -labeling/dating, storage guidelines. -use of hair restraints in order to reduce the risk of cross contamination/spoilage of food items. -maintaining the facility kitchen in a clean, sanitary, and free of dust and debris manner. Findings include: Review of the facility policy titled Dietary Rules, dated July 2020, included the following: -Personal items: should be stored in the office. No bags, jackets, sweaters or purses should be kept in the kitchen . -Drinks and food: Drinks should never be brought into the kitchen from outside. Food from the outside is not allowed in the kitchen for personal consumption. Food may not be consumed in the kitchen except for taste testing (trying food). -Hairnets (hair restraints): must be worn whenever working in the kitchen. A cap may be worn, but if the hair is hanging out of the back (of the cap), it must be in a hairnet under the cap. -Beards: must be kept neat, clean and trimmed. If a beard is not kept short, it must be under a beard/hairnet. Review of the Food and Drug Administration (FDA) Food Code, dated January 2023, included the following: -Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single use articles -an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection can not result. -a food employee may drink from a closed beverage container if the container is handled to prevent contamination of: (1) The employee's hands; (2) The container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During an initial walk-through of the facility kitchen on 10/15/24 at 7:22 A.M., with the Food Service Director (FSD), the surveyor observed the following: -a large fan located in the kitchen near the beverage preparation area that was dust laden. -the front vent of the reach-in refrigerator by the cook's area was dust laden. -the ceiling tile between the cook's stovetop and reach-in refrigerator had observable dust hanging downwards. -the exhaust fan located in the window near the preparation sink was dust laden and sticky to the touch. -the spray hose under the exhaust fan had observable dust and was sticky to the touch. -shelving that had clean pans located near the ovens had dust. -an enclosed bin that had numerous clean measuring cups, spoons and other utensils had food debris on the bottom of the drawers where the items were located. -a pan of covered meat patties, opened wrapped sliced deli cheese, and an opened wrapped deli meat without labels or dates were in the reach-in refrigerator. -pulled unopened clear package of cut up white colored meat without a label or a date in the walk-in refrigerator. -dietary staff personal beverages observed on the lower shelf of the cook's preparation area and on the upper shelf beverage preparation area During an interview at the time, the FSD said the utensils and other items located in the clear bin under the cook's preparation bench needed to be cleaned. The FSD said any food and beverage items located in the refrigerators needed to be labeled and dated when stored for future use. The FSD said personal employee beverages were allowed as long as they were covered and stored below the food preparation areas. The FSD further said the dust on the fans, ceiling, refrigerator vents and shelving needed to be cleaned. During a follow-up walk through of the facility kitchen on 10/18/24 at 2:00 P.M., the surveyor observed the following: -dietary employees observed with facial hair not covered by a beard net in the kitchen. -an employee beverage in a [NAME] Donuts cup and a cell phone charger and cord on a shelf with the cups and covers used for resident service. During an interview at the time, the FSD said that dietary employees with facial hair less than a quarter of an inch or less were not required to wear a beard net. The FSD further said that dietary employee personal items including the beverage and the cell phone charger should not have been stored in the food preparation areas.

Based on observation, interview, record and policy review, the facility failed to maintain an environment that is free of accidents and hazards for two Resident (#103 and #45) out of a total sample of 23 Residents. Specifically, the facility staff failed to: 1. For Resident #103, ensure potentially hazardous smoking materials were stored in a secure area, putting the facility Residents at risk for injury due to inappropriate usage when the Resident was smoking in his/her room. 2. For Resident #45, ensure that an elopement assessment was completed timely and safety interventions were implemented when the Resident demonstrated exit seeking behaviors, resulting in the Resident eloping from the secure (locked) unit via a door that was malfunctioning. Findings include: 1. Review of the facility policy titled Smoking Policy, undated, indicated the following: -Residents are not permitted to have any smoking paraphernalia in their room or on their person. Resident #103 was admitted to the facility in March 2024, with diagnoses including Vascular Dementia (a condition that occurs when the brain does not get enough blood flow, damaging brain tissue and impairing thinking, memory, and behavior) and Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of Resident #103's Smoking Care Plan, initiated 4/8/24, indicated the following: -Resident prefers to actively participate in smoking while residing in facility. -Instruct Resident about the facility policy, location, times, safety concerns. -Notify charge Nurse immediately if it is suspected Resident has violated facility smoking policy. -Resident can smoke with supervision. Review of Resident #103's Smoking and Safety Assessment, dated 8/9/24, indicated the following about the Resident. -smokes tobacco -balance problems while sitting or standing -follows the facility's policy on location and time of smoking -unable to use ashtray to extinguish tobacco or marijuana -unable to light tobacco or marijuana safely -Resident is able to participate in supervised smoking in [sic] facility. Review of the Minimum Date Set (MDS) Assessment, dated 9/24/24, indicated the following: -Brief Interview for Mental Status (BIMS) score of 10 out of a total score of 15 indicating moderate cognitive impairment. -Required substantial/maximal assistance (helper does more than half of the effort) for hygiene and dressing. Review of the facility Resident Smokers list, dated 10/11/24, indicated the following: -All smoking materials will be stored in red box at nurses station and brought out with smokers so that smoking materials can be utilized at time designated for supervised smoking. -Residents regardless of smoking status should keep all smoking materials in the red box. -Resident #103 was identified as a supervised smoker. Review of the October 2024 Physician's orders indicated the following: -Resident may participate in supervised smoking in [sic] facility, date initiated 8/9/24. Review of the Kardex (abbreviated care plan used by direct care givers to receive information quickly relative to providing care) indicated the following: -The Resident can smoke with supervision -Instruct Resident about the facility policy on smoking: locations, times, safety concerns. Review of the Nurses Progress Note, dated 4/17/24, indicated the Resident was observed smoking a lit cigarette in his/her room. The Nurses Progress Note further indicated that a Nurse intervened and extinguished the lit cigarette and removed all smoking material including a lighter from the Resident's room. The Nurses Progress Note indicated that the Nurse met with the Resident to review facility smoking policy and to educate him/her regarding safety risk of flammables in locations that use Oxygen (medical gas used for inhalation therapy and resuscitation that is capable of being ignited and burning) as well as re-education regarding the outside facility smoking location and need for staff supervision with smoking. During an interview on 10/15/24 at 8:42 A.M., Resident #103 said that he/she smokes cigarettes three times a day. The Resident said he/she kept his/her cigarettes and lighter in the nightstand in his/her room. The Resident showed the surveyor a pack of cigarettes and two lighters in the top drawer of his/her nightstand. During an interview on 10/15/24 at 3:53 P.M., the Resident said he/she had gone out to smoke twice that day, and was expecting to go out to smoke again around 4:00 P.M. Resident #103 said that he/she was not sure what the facility policy was about storage of cigarettes and lighters but that he/she kept his/her cigarettes in his/her room because of fear that they will be stolen. The surveyor observed a pack of cigarettes and two lighters in the top drawer of the Resident's nightstand. On 10/15/24 at 3:59 P.M., the surveyor observed Resident #103 being escorted from the nursing unit by Activity Assistant (AA) #1 to the smoking area. The surveyor observed AA #1 provide cigarettes from a red tackle box to some Residents, but did not observe AA #1 provide a cigarette to Resident #103. Resident #103 was observed to be smoking a cigarette. During an interview on 10/15/24 at 4:06 P.M., AA #1 said that she did not give Resident #103 a cigarette because he/she had his/her own. AA #1 said Resident #103 had been keeping cigarettes in his/her room for a while. AA#1 further said that the facility policy was that the Resident's cigarettes and lighters were supposed to be placed in the red tackle box that were kept behind the nurses station. During an interview on 10/15/24 at 4:39 P.M., Nurse #3 said Residents should never have cigarettes or lighters in their rooms. The surveyor observed Nurse #3 enter the Resident's room and ask to check his/her nightstand. The surveyor heard the Resident say the cigarettes have already been taken and that he/she had kept them in his/her room for a long time and everybody knew about it. The Resident said he/she was just going to get more and keep them in his/her room. During an interview on 10/15/24 at 4:45 P.M., the Director of Nursing (DON) said Residents were not permitted to have cigarettes and lighters in their rooms. 37400 2. Resident #45 was admitted to the facility in May 2024, with diagnoses including Cerebrovascular Disease (conditions that affect blood flow to your brain and include stroke, brain aneurysm, brain bleed and carotid artery disease), Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation, unsteadiness on feet, syncope (fainting resulting from certain stressful triggers which lead to sudden drop in blood pressure and heart rate and collapse), repeated falls, fracture of left femur (thigh bone), Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time) of knees and wandering. Review of the facility policy titled Elopement and Wandering, dated May 2024, indicated the center ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and/or elopement. The policy also included the following: -Wandering is a random or repetitive locomotion that may be goal-directed (e.g. the person appears to be searching for something such as an exit) or aimless. -Elopement occurs when a resident leaves the premises or a safe environment without authorization and/or any necessary supervision to do so. -The center is equipped with door locks/alarms to help avoid elopements. -The center shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. -Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: >Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. >Upon completion of assessment if a resident is determined to be an elopement risk, the facility may utilize a personal alarm/device that will alert staff of a residents attempt to leave a secured area. >The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. >The effectiveness of interventions will be evaluated, and changes will be made as needed. Any change or new interventions will be communicated to relevant staff. -Procedure Post-Elopement >A nurse will perform a physical assessment, skin assessment and pain assessment document, and report findings to physician. >Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. >Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions and consultant notes as applicable. Review of the Minimum Data Set (MDS) Assessment, dated 7/12/24, indicated Resident #45: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15. -utilized a walker and wheel chair. -required partial/moderate assistance with transfers. -required supervision with ambulating 10 feet to 50 feet. -ambulating 150 feet and on uneven surfaces was not attempted due to medical conditions or safety concerns. Review of a Nursing Progress Note, dated 8/13/24, indicated Resident #45 was very confused and determined that he/she was not supposed to be in the facility. The Nursing Progress Note indicated the Resident was observed self-propelling around the facility's enclosed courtyard while seated in the wheelchair, and was provided distant supervision from staff for safety because he/she declined returning to the facility. The Resident's Health Care Proxy (HCP: the person (s) chosen as the healthcare decision maker when the individual is unable to do so for themself) was contacted and was agreeable to have the Resident move to a more secure (locked) unit at this time. Review of the clinical record indicated Resident #45 was transferred to the East Two Unit (secured unit) located on the third floor of the facility on 8/13/24. Review of the Nursing Progress Note, dated 8/14/24, indicated Resident #45 became agitated, wanted to go home, and was standing by the secured (unit) door, was trying to unlock the door and was exiting seeking throughout the whole day. Review of the Nursing Progress Note, dated 8/15/24, indicated the Resident was observed walking down the hallway on the first floor. The Nursing Progress Note indicated when the Resident returned to the secure East Two Unit located on the third floor, the Resident said he/she fell down a flight of stairs. The Nursing Progress Note indicated that the Resident's wheelchair was observed in the back stairwell (leaving the secure unit), the stairwell was assessed, and there was no evidence of a fall. The Nursing Progress Note further indicated that the Resident was assessed, and no injuries were present. The Provider (Physician/ Nurse Practitionar [NP]) and HCP were updated and a wanderguard (device that alarms when in close proximity to alarmed doors) was placed on the Resident. Review of the Elopement Assessment, dated 8/15/24, indicated Resident #45 was considered an elopement risk related to: -Wandering behavior which was a pattern or goal directed. -Recently admitted or readmitted and had not accepted the situation. Review of Resident #45's clinical record indicated no documented evidence that the facility completed an Elopement Assessment prior to the one completed on 8/15/24 (after the Resident had eloped) nor evidence that an investigation was completed to determine the circumstances of how the Resident was able to leave the secured unit without staff awareness on 8/15/24. On 10/17/24 at 9:18 A.M., Resident #45 was observed dressed, seated in a wheelchair and propelling in a hallway on the secured unit. The surveyor observed a wanderguard device on the Resident's wrist. During an interview on 10/18/24 on 1:01 P.M., Unit Manager (UM) #1 said Resident #45 was transferred to the secured unit on 8/13/24 because of his/her risk of elopement. UM #1 said she was not present during the (elopement) incident on 8/15/24, when Resident #45 was found off the secured unit, but said she remembered the Resident was found by staff ambulating on the first floor of the facility. UM #1 said the doors on the secured unit were able to be opened when pushed for 15 seconds, but when opened this way, they would alarm. UM #1 said an investigation should have been completed to determine how the Resident was able to exit the secured unit without staff awareness, but she was not a part of this process. UM #1 further said the Director of Nursing (DON) would know more about the elopement incident. On 10/18/24 at 1:20 P.M., the surveyor and UM #1 tested the door to the back hallway on the secured unit. After pressing the door handle for approximately 15 seconds, the alarm sounded, and the door was able to be opened to allow access into the stairwell on the opposite side of the door. The surveyor observed a landing and open railing (approximately lower hip height) and an open stairwell were present beyond the alarmed door. The alarm continued to sound when the surveyor and UM #1 were present in the stairwell after the door closed, and was turned off by pressing the key code inside the secured unit. During an interview at the time, UM #1 said she would have concerns if Residents were able get into the stairwell area. UM #1 said it was not safe for Residents to be in this location (the stairwell) because they could be seriously injured. During an interview on 10/18/24 at 1:45 P.M., the DON said she was present when Resident #45 was in the facility courtyard on 8/13/24. The DON said the Resident attempted to shake and open the gate in the back courtyard wanting to leave and was eventually redirected by staff after several attempts to have him/her return inside the facility. The Resident's family was contacted and agreed to move him/her to a more secure unit for safety. The DON said the Resident was moved to the East Two secured unit on 8/13/24 and an elopement assessment should have been completed at that time, but one was not completed. The DON further said an investigation should have been completed when the Resident was found off the secured unit and located on the first floor but an investigation was not completed. The DON said she was not sure how the Resident was able to leave the secured unit without staff awareness because the alarmed doors should have sounded and needed to be manually turned off by staff once the alarm was sounding. The DON said there was a night when the alarms were not working, but she would have to check into this. During follow-up interviews on 10/18/24 at 2:30 P.M. and 4:00 P.M., the DON said neither she nor the Administrator were in the building during the time of the incident on 8/15/24 with Resident #45, and the Assistant Director of Nurses (ADON), who no longer worked at the facility, had been in charge. The DON said the Resident was found by the Receptionist ambulating on the first floor dressed in a hat, coat and holding a bag. The [NAME] said the Receptionist thought it was a visitor and then recognized the Resident and called for staff assistance. The DON said she was in the process of completing an investigation as one had not been completed during the time of the incident, that the alarms to the secured doors on one unit had not been working during the time, and that she was not aware if any other doors had been affected. The DON said Resident #45 had exited into the back hallway of the secured unit, left his/her wheelchair on the landing, and must have walked down several flights of stairs to get onto the first floor of the facility. The DON said the back doorway to the secure unit was checked after the Resident was located and was observed to be not alarming by staff. The DON said the ADON had alerted her to the Resident's whereabouts and the DON had instructed the ADON to place two stop signs at the back hallway door prior to exiting the secured unit and to have a staff person seated on the other side of the door (on the landing where the stairwell was located) until the electrician could fix the alarmed doors. The DON said she was not sure how long the alarmed doors were not functioning. During an interview on 10/18/24 at 4:34 P.M., the Director of Maintenance (DOM) said the alarming doors for Units South Two and East Two (located in the front part of the facility) were affected during a quarterly fire alarm inspection on 8/14/24. The DOM said when the Unit South Two door was observed to not be alarming, he contacted the electrician who instructed him to check the other facility doors. The DOM said during the checks, he found the Unit East Two (secured unit) door to the back stairwell was not working. The DOM said he contacted administration to alert them of the issue and thought that he was instructed to add a door alarm to the door (alarm that chimed when the door was opened and would shut off when the door was closed), which he said he did. The DOM said typically when an alarmed door was not working, facility staff would be assigned to ensure that no one exited the unit, but was he was unsure if this occurred during the time the secured unit door was not functioning. The DOM said the electrician returned and fixed the doors, but then shortly after the doors were identified to not be working again. The DOM said the electrician returned and had to have a part ordered. The DOM provided the surveyor with an invoice for the door repair dated 8/22/24 (8 days after the door was observed to not be functioning appropriately). The DOM said there were two different alarm systems on the secured unit and during the time frame from 8/14/24 through 8/22/24. The DOM said the wanderguard alarm system was still functioning but would only alert staff if a resident with a wanderguard alarm was near the exit doors. The DOM said he checked the wanderguard alarms weekly and checked the other door alarms quarterly. The DOM said he would not know if the alarmed doors were not functioning between these checks (weekly and quarterly) and would expect the staff to alert him. During an interview on 10/18/24 at 5:12 P.M., the Staff Development Coordinator (SDC) said she was present during the (elopement) incident with Resident #45 on 8/15/24. The SDC said she heard the Receptionist call for assistance and saw Resident #45 ambulating without assistance while leaning against the wall on the first-floor hallway. The SDC said she went to retrieve a wheelchair, and the Resident was assisted back to the secured unit at that time. The SDC said she was not sure what happened after the Resident was returned to the unit. The SDC said the incident occurred around 7:00 A.M. - 7:30 A.M., that she worked until 5:00 P.M. on 8/15/24, and could not recall any instructions about the Resident's elopement at that time. During an interview on 10/18/24 at 5:20 P.M., UM #3 said she received a call from the ADON on 8/15/24 and assisted on the East Two Unit (secured unit). UM #3 said Resident #45 was on the unit at that time and had stated that he/she fell down the stairs. UM #3 said she and the ADON observed the back hallway to the unit and discovered the Resident's wheelchair on the landing. UM #3 said she assessed the hallway and stairwell and observed no signs of an accident or injury and could not recall the alarm sounding when leaving the secured unit and said she would automatically enter the code to exit the unit (despite the Director of Maintenance stating he placed a door alarm on the door). UM #3 said she thought a stop sign was put into place but could not recall other measures put into place at that time and could not recall what was done to ensure the other residents on the secure unit were safe and accounted for. During an interview on 10/18/24 at 5:27 P.M., the Administrator said he was not made aware that several alarmed doors to the facility units were not functioning (on 8/14/24). The Administrator said if this occurred, he would expect facility staff to notify him immediately to determine a plan. The Administrator said a staff person would have been assigned to guard the doors continuously until the affected doors were fixed, and that residents on the affected units would be checked to ensure they were accounted for. The Administrator said he could not verify that the doors were continuously monitored or that residents were accounted for during the dates the doors were first identified as not to be working (8/14/24). The Administrator said he returned to work on 8/20/24 after the event and was not aware of any outcome, did not check to see if there was an incident report about Resident #45 eloping from the secured unit and had just found out that there were multiple times that the alarmed doors had not been functioning during that time.

Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon as required for one Resident (#59), of five applicable residents reviewed for unnecessary medications, out of a total sample of 23 residents. Specifically, the facility failed to act upon the Consultant Pharmacist recommendations dated 8/21/24 and 9/18/24, to include an evaluation and/or stop date for a PRN (as needed) psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication. Findings include: Resident #59 was admitted to the facility July 2024, with diagnoses including unspecified Dementia (the loss of cognitive function, thinking, remembering and reasoning, to such an extent that it interferes with a person's daily life and activities). Review of the October 2024 Physician's orders, indicated the following: -Lorazepam (anti-anxiety medication) oral tablet 0.5 milligrams (mg), give 0.5 mg by mouth every 12 hours as needed (PRN) for Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), start date 8/3/24. Review of the Consultant Pharmacist Recommendations, dated 8/21/24 and 9/18/24, indicated the following: -Lorazepam PRN order needs a stop date/re-evaluation date added to order. Review of the Clinical Record, dated 8/21/24 through 10/16/24 indicated no documented evidence the Consultant Pharmacist recommendations dated 8/21/24 and 9/18/24, had been acted upon. During an interview on 10/17/24 at 1:30 P.M., the Director of Nursing (DON) said that after the Pharmacist has reviewed the residents, the DON and the Unit Mangers (UM), would receive an e-mail with the Pharmacist's Recommendations. The DON said the facility process for pharmacy recommendations was that the UM prints the recommendations for the Physician and puts them in them in a folder for the Physician to address. Once the pharmacy recommendation was addressed, the UM would enter any new orders into the medical record. The DON said that she did not have a system in place for verifying that the pharmacy recommendations had been addressed and said the surveyor should check with the UM. During an interview on 10/17/24 at 1:47 P.M, Nurse #7 said that she had never seen the Consultant Pharmacist's Recommendations for Resident #59 dated 8/21/24 and 9/18/24. Nurse #7 reviewed the Physician Communication book and said she could not find any of the recommendations. During an interview on 10/17/24 at 1:48 P.M., UM #2 said that when she receives the Pharmacist's Recommendations via e-mail, she prints them and puts them in the Physician's book. UM #2 said once the recommendations were approved, she would enter any new orders into the resident's medical record. UM #2 said she did not recall seeing the Pharmacist's Recommendations dated 8/21/24 and 9/18/24, for Resident #59, and offered to look for them. During a follow-up interview on 10/17/24 at 2:13 P.M., UM #2 said she was unable to find any documented evidence that the Pharmacist's Recommendations dated 8/21/24, had been addressed because she had not taken the position as UM until September 2024. UM #2 further said that she had missed the Pharmacist's Recommendations dated 9/18/24. (Refer to F758)

Based on interview, and record review, the facility failed to ensure that a recommendation made by the Behavioral Health Care Team was implemented for one Resident (#104) out of a total sample of 23 residents. Specifically, for Resident #104, the facility failed to ensure that a recommendation made by the Psychiatric Nurse Practitioner to increase the Resident's antianxiety medication after he/she experienced an increase in Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) was reviewed by the Physician and implemented or alternate treatments were put into place. Findings include: Resident #104 was admitted to the facility in February 2024, with diagnoses including Generalized Anxiety Disorder and Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of the Psychiatric Nurse Practitioner's Note dated 10/9/24, indicated the following: -The Resident was seen due to increased Anxiety and recurrence of past behaviors, including increased complaining and attention seeking. -Recommendation to start Ativan (Lorazepam: antianxiety medication) 0.5 milligrams (mg) two times a day (BID). Review of Resident #104's October Physician's order indicated the following: -Lorazepam (Ativan) 0.5 mg (give 1/2 tablet [0.25 mg]) by mouth three times a day, related to Anxiety Disorder, start date of 5/15/24. Review of the October 2024 Certified Nursing Behavior Monitoring/Intervention Flowsheets indicated Resident #104 continued to have verbal and socially inappropriate behaviors daily: -from 10/10/24 through 10/14/24 -and on 10/16/24. During an interview on 10/17/24 at 4:42 P.M., Nurse #5 said notes from the Psychiatric Nurse Practitioner are available the day after she sees a resident. Nurse #5 said the Psychiatric Nurse Practitioner's note gets reviewed by the Unit Manager (UM) and then is placed in the Medical Doctor (MD)/Nurse Practitioner's (NP) book (binder kept on the unit that provides communication between Resident's Health Care Providers and/or Nursing) so it can be reviewed. She said the either the MD or NP is in the building every day so she would expect the recommendation would be reviewed within a couple of days of the recommendation being made. Nurse #5 further said the MD or NP would let nursing know if they wanted to increase the Ativan as recommended or provide alternate treatment and nursing should make a note with the MD or NP's decision or get an order to begin the new medication. Nurse #5 reviewed the MD/NP book and the Resident's medical record and said she was unable to find any documentation the MD or NP had reviewed the Psychiatric Nurse Practitioner's recommendation from 10/9/24. During an interview on 10/17/24 at 4:57 P.M., UM #1 said recommendations made by the Behavioral Health Care Team should be reviewed by the MD or NP within a couple of days of the recommendation being made. UM #1 said she could find no documentation the MD or NP had reviewed the Psychiatric Nurse Practitioner's recommendation to increase Resident #104's Ativan medication.

Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for one Resident #72) out of a total sample of 23 residents. Specifically, the facility failed to ensure that a Level I screen was completed prior to admission to the facility when Resident #72 had active diagnoses of mental disorders. Findings include: Review of the facility policy titled Resident Assessment-Coordination with PASARR Program {sic}, reviewed/revised September 2024, indicated the following: -All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. -PASARR Level 1-initial pre-screening that is completed prior to admission {sic} Resident #72 was admitted to the facility in August 2023, with diagnoses of Paranoid Schizophrenia (type of Schizophrenia characterized by paranoia [distrust, suspicious, and fearful without any good reason], delusions and hallucinations), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review Resident #72's PASRR Level I, dated 8/17/24, indicated it was completed after the Resident was admitted to the facility. During an interview on 10/16/24 at 10:53 A.M., Social Worker (SW) #1 said Resident #72's PASRR Level I was completed post admission to the facility and should have been completed prior to his/her admission to the facility. SW #1 further said she was aware PASRR Level Is were being completed post admission but there was not always a Social Worker in the building to complete the Level I PASRR if a resident was admitted after hours or on a weekend. SW #1 said no other staff members in the facility had been trained to complete the PASRR Level I screening.

Based on interview, and record review, the facility failed to ensure that professional standards of care were maintained for diabetic management for one Resident (#8) out of a total sample of 23 residents. Specifically, for Resident #8, the facility failed to ensure that Physician's orders were implemented and Physician notification occurred when the Resident experienced periods of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Findings include: Review of the facility policy titled Blood Glucose Monitoring, undated, indicated the following: -The facility will perform blood glucose monitoring as per Physician's orders. -License Nurse to follow Physician orders set for high and low parameters. Review of the facility policy titled Hypoglycemia Management, reviewed/revised February 2024, indicated the following: -Diabetic residents will have their blood sugar tested as per Practitioner's (Physician/ Nurse Practitioner) orders. -If the blood glucose (blood sugar) reading is 60 milligram (ml)/deciliter (dL) [ml/dL: a unit of measure used for blood glucose testing] or below, the Nurse will utilize the hypoglycemic protocol as per the Practitioner's orders, will follow up blood glucoses as indicated, and notify the Practitioner of the results as ordered. Resident #8 was admitted to the facility in August 2013, with a diagnosis of Type I Diabetes (insulin-dependent-diabetes: a lifelong condition where the pancreas makes little or no insulin, which leads to changes in blood sugar levels). Review of Resident #8's Diabetic Care Plan, initiated 4/13/18, indicated the following: -Attempt to resolve hypo-hyperglycemia for blood sugar outside parameters for this Resident per house protocol. -Report to Medical Doctor (MD) PRN (pro re nata: as needed) as indicated for blood sugar (BS) outside designated parameters. Review of Resident #8's October 2024 Physician's orders indicated the following orders: -If blood sugar is less than 60 ml/dL administer: >4 ounces (oz) juice or >6 oz regular soda or >1 tube of glucose gel (medication used to increase blood sugar), -Repeat BS in 15 minutes, if still less than 60 ml/dL: >repeat 4 oz juice. -If no change in 15 minutes, report to MD as needed, start date 2/9/19 -Admelog SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ML (insulin medication used to treat diabetes), inject as per sliding scale . -Blood sugar greater than 400 ml/dL, update Primary Care Provider (PCP)/Nurse Practitioner (NP). Review of Resident #8's August 2024 Medication Administration Record (MAR) indicated the following: -8/15/24: blood sugar result of 50 ml/dL. Review of the August MAR and the Nursing Progress Notes from 8/15/24, indicated: -no documentation that the Resident had been offered juice, soda, or glucose gel -no documentation that the Resident's blood sugar had been retested after 15 minutes to determine if the blood sugar had increased. Review of Resident #8's September 2024 MAR indicated the following: -9/11/24: blood sugar result was 58 ml/dL -9/15/24: blood sugar result was 58 ml/dL -9/21/24: blood sugar result was 441 ml/dL at 11:00 A.M. and 9:00 P.M. Review of the September MAR and the Nursing Progress Notes from 9/11/24 and 9/15/24 indicated: -no documentation that the Resident had been offered juice, soda, or glucose gel -no documentation that the Resident's blood sugar had been retested after 15 minutes to determine if the blood sugar had increased on 9/11/24 or 9/15/24. -no documentation that the Resident's PCP had been updated that the Resident had blood sugar levels over 400 ml/dL two times on 9/21/24. During an interview on 10/15/24 at 4:40 P.M., Nurse #1 said if a Resident had a blood sugar lower than 60 ml/dL the Nurse should provide the Resident with juice, soda, or glucose gel as per the Physician's order. Nurse #1 said then the blood sugar would be retested to make sure it had increased. Nurse #1 said this should be documented on the MAR to show which treatment was provided to raise a low blood sugar. Nurse #1 further said if a Resident had a blood sugar over 400 ml/dL the Nurse should notify the Resident's PCP and get orders on how much additional insulin to administer to the Resident to lower the blood sugar. Nurse #1 said this would be documented in the Nursing Progress Notes. During an interview on 10/15/24 at 5:02 P.M., Unit Manager (UM) #1 said each Resident who is at risk for hypo/hyperglycemia will have Physician's orders with the parameters for blood sugars and what should be done if a Resident becomes hypo/hyperglycemic. The surveyor and UM #1 reviewed Resident #8's Physician's orders and UM #1 said if the Resident had a blood sugar level less than 60 ml/dL, staff should have administered juice, soda, or glucose gel as ordered and rechecked the Resident's blood sugar after 15 minutes and documentation should be completed on the MAR. UM #1 further said if Resident #8 had a blood sugar level over 400 ml/dL, the Resident's PCP should have been contacted for orders on lowering the Resident's blood sugars and documentation of the conversation and instructions from the PCP should be documented in a Nursing Progress Note. UM #1 reviewed the following dates on the Resident's MAR and Nursing Progress Notes: 8/15/24, 9/11/24, 9/15/24, and 9/21/24, and said she could find no documentation to show what treatment was implemented when the Resident had experienced episodes of hypoglycemia on 8/15/24, 9/11/24, and 9/15/24. UM #1 also said she could find no documentation to show the PCP had been updated when the Resident experienced two episodes of hyperglycemia on 9/21/24.

Based on interview, record review and policy review, the facility failed to notify a Resident Representative of a change in condition, for one Resident (#5) out of a total sample of 23 residents. Specifically, the facility failed to notify Resident #5's Representative when the Resident developed a skin rash which required an outpatient appointment to a Dermatologist and medication to treat the condition. Findings include: Review of the facility policy titled Notification of Changes, reviewed/revised May 2024, indicated the facility promptly informs the resident, consults with the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The policy included the following: -Circumstances requiring notification include: >significant change in the resident's physical condition .which may include clinical complications . >circumstances that require a need to alter treatment . and may include a new treatment >a transfer .from the facility -Competent individuals: >the facility will notify the resident's representative, if known >when a resident is mentally competent, a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally . -Resident incapable of making decisions: >the representative would make any decisions that would have to be made >the resident should still be told what is happening to him or her Resident # 5 was admitted to the facility in October 2023, with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the October 2024 Physician's orders indicated the following: -invoke (put into effect) the Resident's Health Care Proxy (HCP: the person chosen as the healthcare decision maker when the individual is unable to do so for themself) as of 9/6/23, initiated 9/7/23 Review of the Minimum Data Set (MDS) Assessment, dated 10/4/24, indicated Resident #5: -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15. -required partial to moderate assistance with activities of daily living (ADLS: basic tasks like bathing, dressing and eating). Review of the Resident #5's clinical record included the following: -Nursing Progress Note, dated 10/8/24, indicated that the Resident was complaining of being very itchy and was observed to have a raised rash on his/her bilateral (both) hands. The Nurse requested the Wound Team assess the areas, and an outside appointment was made with Dermatology for 2:00 P.M. that day. -Wound Consultation Note, dated 10/8/24, indicated the Resident had an evaluation for scabies (contagious skin rash caused by infestation of tiny burrowing human itch mites that causes intense itching and a pimple-like rash) rash on his/her abdomen, chest, neck, hands, and bilateral legs. The areas had linear indurated (thickening and hardening of the skin in a line pattern) rash with erythema (redness) and itchiness that worsened at night. -Nurse Practitioner (NP) Progress Note, dated 10/9/24, (late entry for 10/8/24), indicated the Resident presented with a rash and intermittent itchiness to his/her arms, neck and right leg. There was concern for scabies and it was recommended that the Resident be seen by Dermatology for definitive diagnosis and for the facility to maintain precautions. -Dermatology Consult, dated 10/8/24, indicated the Dermatologist was unable to determine if scabies was present, but recommended treatment for scabies which included Permethrin Cream (scabicide) and Triamcinolone Cream (topical corticosteroid cream used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions). Review of the October 2024 Physician's orders, indicated the following order was initiated on 10/8/24 at 4:00 P.M. (upon the Resident's return from the Dermatology Consult): -Permethrin Cream 5% from the neck down, then shower eight hours later, and repeat the treatment on 10/18/24 (one week later), for treatment of Scabies. -Triamcinolone Cream 1% two times daily for two weeks, then daily for one month. Review of the Medication Administration Record (MAR) for October 2024, indicated the Permethrin Cream for Scabies treatment was administered to Resident #5 on 10/11/24. Review of the Resident's clinical record indicated no documented evidence that the Resident's Representative was notified of the Resident's change in condition. During an interview on 10/18/24 at 7:21 A.M., the Director of Nursing (DON) said she was unable to find evidence that the Resident's Representative was notified of his/her change in condition that occurred on 10/8/24, and subsequent treatment for scabies. The DON said a change of condition should have been completed after the Resident was identified as having the skin rash and the Resident Representative should have been notified. The DON said Resident #5's Representative was contacted on 10/17/24, after the surveyor inquiry. Refer to F880

Based on interview, record and policy review, the facility failed to provide a dignified experience for one Resident (#19) out of a total sample of 23 residents. Specifically, for Resident #19, the facility failed to provide incontinence care after the Resident was incontinent of bowel and prior to engaging in a group activity. Findings include: Review of the facility policy titled Dignity, revised May 2024, indicated the following: -That each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -Demeaning practices and standards of care that compromise dignity are prohibited. -Staff are expected to promote dignity and assist residents; for example: .promptly responding to a resident's request for toileting assistance . Resident #19 was admitted to the facility in August 2024, with diagnoses including repeated falls, Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity), need for assistance with personal care, and unsteadiness on feet. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the Resident was cognitively intact. Review of Resident #19's individualized care plan indicated the following: -Resident is incontinent of bladder and bowel due to physical limitations, initiated on 8/26/24 -Clean peri-area with each incontinence episode, initiated on 8/26/24 -Resident has an ADL (Activities of Daily Living) performance deficit due to disease process, initiated on 8/29/24 -Personal Hygiene: Resident requires assist of one staff, initiated on 8/29/24 and revised on 9/5/24 -Toilet Use: Resident requires assist of one staff, initiated on 8/29/24 and revised on 9/5/24 -Transfers: Resident requires assist of one staff, two assist when fatigued, initiated on 8/29/24 and revised on 9/5/24 -Resident can smoke with supervision, initiated on 8/16/24 Review of the facility smoking schedule titled, Smoking Time and Location, updated on 9/15/24, provided by the facility during the entrance conference indicated the following daily smoking times: -9:30 A.M. -1:30 P.M. -4:30 P.M. -7:00 P.M. During an interview on 10/15/24 at 11:34 A.M., Resident #19 said that last week, around the 9:30 A.M. smoking time, the Resident told Nurse #4 that he/she had a bowel movement and needed to be changed before going downstairs to smoke. Resident #19 said that he/she was told by Nurse #4 that if he/she did not go out to the scheduled smoking time at 9:30 A.M., that the Resident would not be able to go out for a cigarette until the 1:00 P.M., scheduled smoking time. Resident #19 said that he/she did not want to miss the 9:30 A.M. smoking time and did not want to wait until the next scheduled smoking time at 1:00 P.M. The Resident said that he/she went outside to have his/her cigarette while sitting in a bowel movement. Resident #19 said that it was embarrassing and he/she sat away from everyone while smoking outside. During an interview on 10/16/24 at 10:13 A.M., Nurse #4 said that she was in the Resident's room around 9:15 A.M., when the interaction between her and Resident #19 occurred. Nurse #4 said that other residents had already been brought downstairs to the smoking area. Nurse #4 said that Resident #19 was in mid-transfer to a wheelchair when Resident #19 told her that he/she had a bowel movement and needed to be cleaned. Nurse #4 said that she gave the Resident three options: 1) be cleaned now and wait until the 1:00 P.M. scheduled smoking time, 2) go downstairs now for his/her smoking time and get cleaned up when the Resident came back upstairs, or 3) get cleaned up now and maybe Nurse #4 could find someone to bring the Resident down at some point in the morning to have a cigarette. Nurse #4 said that it was hard because she is only one Nurse to 24 residents with two Certified Nurses Aide (CNAs) and that it was not possible for a Nurse or the CNAs to leave the unit for an extended period of time to take a Resident to smoke. Nurse #4 said that the Resident was sometimes incontinent of bowels but felt that it was a behavior, and that Resident #19 knows when he/she needed to use the bathroom. Nurse #4 said that she gave the Resident three options, and the Resident chose to go downstairs to smoke. During a follow-up interview on 10/16/24 at 10:25 A.M., Nurse #4 said that CNA #4 was also in the Resident's room when the interaction occurred and that she was not alone with the Resident. During an interview on 10/16/24 at 10:31 A.M., Unit Manager (UM) #3 said that to maintain dignity for the Resident, incontinence care should have been provided and then the Resident should have been brought down to the smoking area. UM #3 said that since it was 9:15 A.M., before the scheduled smoking time, care should have been provided. UM #3 said that someone else, like the Activities Aide is down in the smoking area and provided supervision. UM #3 said that the nursing staff (cart Nurse or the CNA's) would not have been required to sit with the Resident. During a follow-up interview on 10/16/24 at 10:52 A.M., UM #3 said that she talked with the staff and learned that the Resident was adamant that he/she go downstairs and smoke, to the point where he/she was trying to self-transfer from the bed into the wheelchair. UM #3 said that the staff informed her that the Resident had already been cleaned up two to three times prior to Resident #19 notifying the staff that he/she had another bowel movement. During an interview on 10/16/24 at 11:04 A.M., CNA #4 said that Resident #19 said that the he/she had a bowel movement while in the middle of transferring with a mechanical lift from the bed to the wheelchair. CNA #4 said that the Resident became agitated, because he/she did not want to miss the smoking time and said that he/she would change when he/she came back upstairs. CNA #4 said that the Resident refused to sit on the toilet and that this is an ongoing situation. During an interview on 10/16/24 at 4:41 P.M., the Director of Nursing (DON) said that she talked with Nurse #4 prior to this conversation and the situation was explained. The DON said that the smoking time is not exactly a hard and fast time and that since other residents had been brought down 15 minutes earlier than the scheduled 9:30 A.M. smoking time, Resident #19 could have been cleaned up and then brought down to have his/her cigarette.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#35 and #23) out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #35, ensure that Physician's orders were in place to address the liter flow (LPM-flow rate of Oxygen that is received from an oxygen delivery device) of Oxygen and appropriate maintenance and storage were in place for the Resident's nebulizer (machine that administers medication via a mist that is inhaled) device. 2. For Resident #23, notify the Provider timely for updated orders/interventions when there was a change in the Resident's condition and Oxygen was no longer being administered continuously per Physician's orders. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Oxygen therapy should be administered in accordance with the Physician prescription. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. Review of the facility policy titled Oxygen Administration, date reviewed/revised May 2024, indicated the following: -Oxygen is administered to resident who need it, consistent with professional standards of practice -Oxygen is administered under orders of a physician . -The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as but not limited to: -The type of oxygen delivery system. -When to administer, such as continuous or intermittent and/or when to discontinue. -Equipment setting for prescribed flow rates. -Cleaning and care of equipment shall be in accordance with facility policies for such equipment. -Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations . 1.Resident #35 was admitted to the facility in January 2022 with a history of tobacco use. Review of the Physician Progress Note dated 10/11/24, indicated the Resident had a new onset of cough and congestion and was started on supplemental Oxygen set at 2 LPM. On 10/15/24 at 9:29 A.M., the surveyor observed Resident #35 in his/her room, seated in a wheelchair, and receiving supplemental Oxygen set at 2 LPM via a nasal cannula (NC: a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs). The surveyor observed a nebulizer machine on the Resident's bedside table with the aerosol mask (mask attached to the nebulizer machine and applied to the face when a mouthpiece device cannot be used) was uncovered and a plastic storage bag (used to store the oxygen tubing and nebulizer mask when not in use) dated 10/12/24, laying on the bedroom floor. On 10/16/24 at 10:37 A.M., the surveyor and Nurse #2 observed the Resident in his/her room, seated in a wheelchair, receiving Oxygen set at 2 LPM via nasal cannula. The Resident's nebulizer was observed on the Resident's bedside table, covered with the plastic bag dated 10/12/24. Review of Resident #35's October 2024 Physician's orders indicated the following order: -Apply O2 (Oxygen) via NS [sic] to maintain pox (pulse oximetry/ oxygen saturation/SpO2 - method of monitoring Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) at 90% or above every shift for shortness of breath (SOB), start date 10/11/24. Further review of the October 2024 Physician's orders indicated no order for the liter flow (LPM) of Oxygen that the Resident should be receiving. During an interview on 10/16/24 at 10:43 A.M., the surveyor shared with Nurse #2 the photo taken on 10/15/24 of the plastic storage bag dated 10/12/24 laying on the floor in Resident #35's room. Nurse #2 said someone should not have placed the plastic bag back on the Resident's nebulizer mask and tubing after it had touched the floor. Nurse #2 said a new storage bag should have been obtained, as a storage bag for respiratory equipment coming into contact with the floor is an infection control concern. During a follow-up interview on 10/16/24 at 11:03 A.M., Nurse #2 said she had reviewed Resident #35's Physician's orders and she was unable to locate an order for the LPM the Resident's Oxygen should be set at. Nurse #2 further said the Physician order should indicate what the prescribed LPM is, so the facility staff could set the oxygen delivery equipment correctly. 50563 2. Resident #23 was admitted to the facility in July 2016, with diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue), Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #23's Physician orders indicated the following: -Oxygen at 2 liters per minute via nasal cannula continuously to maintain SPO2 of 90% or better, initiated 4/12/24 with no stop date. Review of Resident #23's Nursing Progress Notes indicated that Oxygen was not administered (not being used continuously) on the following dates/times: -8/5/24 at 4:42 P.M. -8/6/24 at 9:11 A.M. -8/9/24 at 12:15 P.M. -8/13/24 at 11:40 A.M. -8/16/24 at 5:11 P.M. -9/24/24 at 5:02 P.M. -9/27/24 at 1:22 P.M. -9/30/24 at 4:48 P.M. -10/1/24 at 5:47 P.M. -10/4/24 at 12:53 P.M. -10/8/24 at 1:22 P.M. -10/16/24 at 3:57 P.M. Further review of Resident #23's Nursing Progress Notes indicated the following documented SPO2 levels: -9/6/24: SPO2 level on room air (no supplemental Oxygen use) documented as 91% -10/1/24: SPO2 level on room air documented as 96% -10/16/24: SPO2 level on room air documented as 93% Review of Resident #23's Oxygen Use Care Plan, initiated on 4/12/24, indicated to administer Oxygen as ordered. The surveyor observed Resident #23 without Oxygen in use on the following date and times: -10/15/24 at 9:46 A.M. -10/16/24 at 8:42 A.M. -10/16/24 at 2:45 P.M. -10/17/24 at 9:29 A.M. -10/18/24 at 8:36 A.M. -10/18/24 at 10:05 A.M. During an interview on 10/18/24 at 10:08 A.M. the surveyor and Nurse #9 reviewed Resident #2's oxygen order. Nurse #9 said the order indicated Oxygen was to be administered continuously which meant it should be on all the time. Nurse #9 further said that the Resident's SPO2 levels had been good but that until reviewed with the Provider and a new order is obtained to administer Oxygen as needed (PRN) instead of continuously, that the oxygen should not have been removed. During an interview on 10/18/24 at 10:13 A.M., the surveyor and the Nurse Practitioner (NP) reviewed Resident #23's order for continuous Oxygen administration. The NP said that Nurse #9 had reviewed this with her today and she gave an order for as needed (PRN) Oxygen administration as the Resident was not requiring Oxygen continuously any longer. The NP further said that before today she does not recall ever being notified that the Resident was not requiring continuous Oxygen or having a Nurse request an order change relative to Oxygen administration. During an interview on 10/18/24 at 12:42 P.M., Unit Manager (UM) #1 said that if an order reads to administer Oxygen continuously that the expectation is the Oxygen would be on at all times. UM #1 further said that the expectation is if a Nurse identified the Resident was not requiring Oxygen continuously any longer, that they should notify the Provider and obtain an order change before removing the Oxygen.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a wheelchair for mobility, the Facility failed to ensure his/her safety was maintained to prevent incidents resulting in an injury. On 1/04/21, Certified Nurse Aide (CNA) #1 was propelling Resident #1 in his/her wheelchair, Resident #1 fell forward out of the wheelchair onto the floor. Resident #1 was transferred to the Hospital Emergency Department for evaluation, he/she required 11 staples to close a 10 centimeter laceration to his/her forehead, and was diagnosed with an acute fracture of his/her second Cervical (C2) spine (neck fracture). Findings include: The Facility's Policy, titled Managing Falls and Falls Risk, dated 3/2021, indicated a fall was defined as unintentionally coming to rest on the ground, and fall risk factors included cognitive impairment and functional impairments. Resident #1 was admitted to the Facility in October 2017, diagnoses included dementia, falls, and muscle weakness. Review of Resident #1's Care Plan related to Falls, dated as revised 8/23/20, indicated he/she was at risk for falls due to gait and balance problems, poor safety awareness, and history of falls. Review of Resident #1's Activities of Daily Living Care Plan, dated as revised 8/23/20, indicated he/she self-propelled in a wheelchair and at times required one person assistance from staff due to fatigue or weakness. Review of The Facility's Internal Investigation Summary, dated 01/04/21, indicated CNA #1 attempted to assist Resident #1 to transport back to his/her room, after Resident #1 had fallen asleep in his/her wheelchair. The Summary indicated as CNA #1 was pushing the wheelchair, Resident #1 fell forward out of his/her wheelchair onto the floor. Review of the Progress Note written by Nurse #5, dated 01/04/21, indicated she heard a bang, and observed Resident #1 lying face down on the floor in front of his/her wheelchair. The Note indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation. During interview on 9/28/21 at 9:02 A.M., Nurse #5 said Resident #1 was known to self propel using his/her feet around the unit in his/her wheelchair and did not use leg rests. Nurse #5 said that on 1/04/21, at 11:00 P.M., she was at the Nurses' station and heard a loud bang. Nurse #5 said she observed Resident #1 was on the floor in the hallway, and that CNA #1 said Resident #1 had fallen out of the wheelchair. Nurse #5 said she reviewed the facility's video surveillance footage of the incident, and said the video showed Resident #1 been sitting in his/her wheelchair at the end of the hall, that he/she appeared sleepy,with his/her head bowed down. Nurse #5 said Resident #1's feet were tucked under his/her wheelchair. Nurse #5 said CNA #1 could be seen on the video saying something to Resident #1, walks away from him/her and then went into another room. Nurse #5 said CNA #1 can then be seen in the video, approaching Resident #1 from behind, and then pushing Resident #1 forward in the wheelchair. Nurse #5 said in the video she could see as the front toe portion of Resident #1's shoes stuck to the floor, and then Resident #1 is propelled forward out of the wheelchair and lands face down on the floor. Review of Resident #1's Hospital Discharge Summary, dated 1/04/21, indicated Resident #1 sustained a 10 centimeter long laceration to his/her forehead which required 11 staples to close, and was diagnosed with an acute fracture of the second cervical (neck) bone. During interview on 9/14/21 at 2:20 A.M., the Director of Nurses said the facility's investigation revealed that CNA #1 approached Resident #1 from behind, and when CNA #1 attempted to push Resident #1's wheelchair forward, Resident #1's feet were tucked under his/her wheelchair and the toes of his/her shoes got stuck on the floor, causing Resident #1 to be propelled forward and out of the wheelchair, landing on his/her face on the floor. The Director of Nurses said, to maintain resident safety, she would expect that staff would make sure residents were awake, or aware of what is going to happen, before attempting to transport them. Certified Nurse Aide #1 did not respond to the surveyors request for an interview.

Based on observations, interviews and record reviews for one of three sampled residents, (Resident #1), who required close supervision by staff during meals, the Facility failed to ensure his/her safety was maintained and that he/she was provided with adequate supervision to prevent an incident with an injury. On 2/10/20, Resident #1 was left unsupervised by staff while in the 1:8 feeding group, he/she spilled a cup of hot tea onto her/his lap, and sustained a second degree burn (a partial thickness burn) to her/his left upper thigh. Findings include: Resident #1 was admitted to the Facility in February 2018 with [DIAGNOSES REDACTED]. Review of Speech and Language Therapy documentation, dated 9/5/19 through 10/25/19, indicated that Resident #1 required close supervision by staff during meals. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired, was dependent on staff for completion of all activities of daily living and required extensive assistance of one staff person for eating. Review of the Nutritional Quarterly Assessment, dated 12/28/19, indicated that Resident #1 was on a house ground texture diet, thin liquids, was to take all meals in dining room and was to be supervised by staff at all meals. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, (indicates residents' level of care and assistance needed), dated as revised February 2020, indicated Resident #1 required continual supervision and cueing with meals and for Resident #1 to eat in the supervised dining room with a group of 1:8 (one staff member for eight residents). Review of the Facility's Policy titled Assistance with Meals, dated as revised September 2013, indicated that residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Review of the Facility Incident Report, dated 2/10/20, indicated that Resident #1 was in the dining room, dropped his/her tea cup and burned his/her left leg. The Report indicated that the Director of Nurses and the Unit Manager went to assess Resident #1 the morning following the incident and observed a blister had developed, as a result of the burn. The Skin Assessment, dated 2/10/20, indicated Resident #1's burn was approximately 15 centimeters (cm) long, 5 cm wide, and there was noted to be loose skin at base of burn. Review of the Physician's telephone order, dated 2/11/20, indicated to cover the anterior left upper thigh burn with petroleum jelly saturated dressing and [MEDICATION NAME], may use ice on area for comfort, reassess area for changes every shift and reapply dressing as needed. During an interview on 2/20/20 at 10:45 A.M., the Registered Dietician said that Resident #1 could be impulsive if he/she really wanted something and that even though he/she appeared frail, could strike out or grab something if determined. During an interview on 2/25/20 at 10:45 A.M., Certified Nurse Aide (CNA) #3 said that on 2/20/20 she was assigned to the 1:8 feeding group for the supper meal. CNA #3 said that she was responsible for supervising the residents in the 1:8 group during the meal while they were eating. CNA #3 said she was also the one responsible for passing out the trays (for the residents in the 1:8 group) from the meal truck and getting their drinks. CNA #3 said the meal truck was located outside the actual dining area where the residents were seated and said she could not effectively supervise residents with their meals until all of the residents in the 1:8 group got their trays. CNA #3 said that Resident #1 rarely takes a hot drink, but requested one that evening. CNA #3 said that she placed a cup of hot tea that had a lid on it, with a straw placed in the hole in the lid and put it on the table in front of Resident #1. CNA #3 said she told Resident #1 to be careful that the tea was hot and left Resident #1 with the cup of tea, so she could pass out more trays. CNA #3 said she stepped out of the 1:8 group dining area, to just around the corner to get more dinner trays out of the food truck (which is out of the view of the residents). CNA #3 said she heard Resident #1 yell out and said she ran back in the dining room to find out why. CNA #3 said that a family member was in the dining room, and told her that Resident #1 had reached for the tea cup and spilled the hot tea on her/his lap. CNA #3 said the family member told her she put Resident #1's tea cup back on the table. CNA #3 said she looked at Resident #1's clothing, did not see a lot of water on Resident #1's lap, but said Resident #1 said it burns! CNA #3 said that she lifted Resident #1's pant leg and saw the top layer of skin on his/her left thigh looked like a burn. CNA#3 said that she wheeled Resident #1 out of the dining room, brought him/her to Nurse #2 and reported the injury. During an interview on 2/20/20 at 2:33 P.M., Nurse #2 said she took a look at Resident #1's left leg and saw a round, reddened area. Nurse #2 said Resident #1 said it hurt like hell. Nurse #2 said she assessed Resident #1's burn, put ice on it and called the physician who gave orders for a dressing.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to supervise Resident #1 in the bathroom, who was a high fall risk and whose plan of care included the use of personal alarms. Resident #1 was left in the bathroom unsupervised, fell off the toilet, was sent to the Hospital Emergency Department for evaluation and was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. A Fall Risk Evaluation, dated 05/13/no year documented, indicated Resident #1 was a high risk for falls. A Fall Risk Care Plan, dated as initiated on 05/14/19, indicated Resident #1 was at risk for falls due to deconditioning, gait/balance problems, pain, pelvic fracture, and history of falls. An Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 usually understands (misses some part/intent of message but comprehends most conversations), was moderately cognitively impaired, required an extensive assist of two staff persons for transfers and toilet use. The MDS indicated Resident #1 had a history of [REDACTED]. A physician's orders [REDACTED]. A Radiology Report, dated 05/21/19, indicated Resident #1's x-rays of the left ribs and left scapula had no acute fractures noted. The Surveyor interviewed Radiologist #1 at 2:30 P.M. on 07/30/19. Radiologist #1 said the x-ray obtained on 05/21/19 of Resident #1's left scapula said the left clavicle was visible in the x-ray and there was no fracture seen at the left medial aspect of the clavicle. A Nurse Progress Note, dated 05/23/19, indicated at 4:20 P.M., Resident #1 stood up from the toilet, lost his/her balance and fell on the right side with legs and arms straight out. The Note indicated Resident #1 complained of right sided hip pain and a headache. The Note indicated the Physician Assistant evaluated Resident #1 and ordered him/her to be transferred to the Hospital Emergency Department for evaluation. The Resident Event Report Worksheet, dated 05/23/19, indicated at 4:20 P.M., Resident #1 had a fall with significant injury in the bathroom that resulted in Resident #1 sustaining a left clavicle fracture. The Report indicated Resident #1 required the use of a safety alarm and that the safety alarm was not in use at the time of the fall in accordance with Resident #1's plan of care. A Verbal Telephone physician's orders [REDACTED]. The Facility Investigation, completed on 05/31/19, indicated Resident #1 was left in the bathroom unsupervised, he/she stood up from the toilet and fell on his/her right side. The Investigation indicated Resident #1 used a personal alarm as a safety device. The Investigation indicated that due to Resident #1's dementia he/she was unable to associate the call bell with requesting assistance to transfer and he/she was unaware that he/she could not independently transfer. The Investigation indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 10:39 [NAME]M. on 07/30/19. CNA #2 said Resident #1 had short term memory loss and was impatient. CNA #2 said Resident #1 used personal alarms and could not be left alone in the bathroom. CNA #2 said any resident that used personal alarms cannot be left alone in the bathroom. The Surveyor interviewed Nurse #2 at 11:52 [NAME]M. on 07/30/19. Nurse #2 said Resident #1 was a high fall risk, was not reliable using a call light, and would not always wait for assistance. Nurse #2 said if a resident used a personal alarm they should not be left unsupervised in the bathroom. The Surveyor interviewed the Director of Rehab at 11:24 [NAME]M. on 07/30/19. The Director of Rehab said Resident #1 was a high fall risk, required supervision with toileting, and should not have been left unsupervised in the bathroom. The Director of Rehab said if a resident used a personal alarm they should not be left unsupervised in the bathroom. The Surveyor interviewed Certified Nurse Aide #1 at 2:44 P.M. on 07/30/19. CNA #1 said Resident #1 had asked to go to the bathroom though he/she had just gone to the bathroom and must have forgotten. CNA #1 said when she transferred Resident #1 from the wheelchair to the toilet, she noticed Resident #1 had a personal alarm on his/her wheelchair. CNA#1 said the bathroom was located inside of Resident #1's bedroom. CNA #1 said she gave Resident #1 the call light, left the bathroom door slightly opened, and waited outside of the bedroom and was in the hallway. CNA #1 said she heard a noise, went to Resident #1's bathroom and found Resident #1 on the floor. CNA #1 said Resident #1 did not put the call light on. CNA #1 said she did not receive report on Resident #1 or review Resident #1's plan of care prior to taking Resident #1 to the bathroom. CNA #1 said she was not sure if a resident with a personal alarm could be left in the bathroom unsupervised. The Surveyor interviewed Nurse #1 at 3:22 P.M. on 07/30/19. Nurse #1 said he was alerted by a family member that Resident #1 needed help. Nurse #1 said he went to the room and found Resident #1 lying on the bathroom floor on his/her back and he/she was complaining of right hip pain. Nurse #1 said he called the physician assistant to the unit, he assessed Resident #1, and ordered for Resident #1 to be transferred to the Hospital Emergency Department for evaluation. Nurse #1 said Resident #1 was a fall risk, used personal alarms, and should not have been left unsupervised in the bathroom. Nurse #1 said if a resident used a personal alarm they should not be left in the bathroom unsupervised. The Surveyor interviewed the Director of Nurses (DON) at 12:16 P.M. on 07/30/19. The DON said Resident #1 was a high fall risk and used a personal alarm. The DON said that if a resident used a personal alarm they should not be left unsupervised in the bathroom. The Hospital Discharge Paperwork, dated 05/23/19, indicated Resident #1 sustained a medial aspect left clavicle fracture.

Based on observation, interviews and record review, the facility staff failed to ensure that one Resident (#156) was provided pain management in a timely manner and according to the physician's orders [REDACTED]. Findings include: Resident #156 was admitted from the hospital to the facility for rehabilitation therapy in 5/2018 with multiple [DIAGNOSES REDACTED]. Review of the Physical Therapy Evaluation and Plan of Treatment documentation, dated, 5/14/18, indicated the resident's trunk range of motion (ROM) was impaired, and had limited active ROM due to lumbar compression fracture with a 10/10 pain level. Review of a nurse's note, dated 5/14/18 at 2:20 P.M., indicated the resident had complained of severe pain but did not want to take the medication [MEDICATION NAME] or Tylenol that was prescribed as it made him/her nauseous. The resident requested [MEDICATION NAME], and the Physician was called. Review of Physician orders [REDACTED].M., for [MEDICATION NAME] IR (immediate release) 15 milligrams (mg.) by mouth every 6 hours as needed for severe pain. Review of a nurse's note, dated 5/14/18 10:48 P.M., indicated the resident was alert, oriented, able to make his/her needs known, had a poor appetite and refused to get out of bed. Observation of Resident #156 on 5/15/18 at 8:36 A.M., in bed, the resident said to the surveyor he/she was in pain and was not getting pain medication. They ordered a different medicine yesterday (5/14/18) and they said it would come in tomorrow, it is not here yet. The resident said he/she was tired and wanted to die. The resident's phone rang, he/she answered the phone and began crying and said I'm in pain and can't take it any more. At this point, the surveyor left the room to report to the facility nurse the resident's statement of being in pain and wanting to die. During an interview on 05/15/18 8:42 A.M. with Nurse #1, who was at the medication cart near the resident's room, said the resident had Tylenol of her own but it was not in the medication cart. Review of a nurse's note, dated 5/15/18 at 1:55 P.M., indicated the resident complained of lower back pain and was medicated with Tylenol 1,000 mg. at 8:50 A.M. The note further indicated an order for [REDACTED]. On 5/15/18 at 3:31 P.M., the surveyor observed the resident in bed. He/she said, I was supposed to work with therapy but did not because I was in to much pain. My pain medication is supposed to come in tonight. Review of the Narcotic book indicated the medication [MEDICATION NAME] IR 15 mg. arrived from the pharmacy 5/15/18 at 4:45 P.M Review of a nurse's note, dated 5/15/18 at 10:36 P.M., indicated the resident was medicated with [MEDICATION NAME] 15 mg. at 4:50 PM for a pain level of 10/10 with good effect resulting in a post medication pain level of 4/10. Review of the facility dietician's note, dated 5/17/18, indicated the resident did not eat well during initial admission period due to pain. The note indicated on 5/14/18 that although the resident could communicate his/her needs, he/she was in so much pain the dietician reviewed the resident's menu with visitors that were advocating for him/her. The note further indicated that on 5/16/18, the resident reported his/her pain was much better controlled and had been eating better. During an interview on 5/18/18 at 8:27 A.M. Unit Manager (UM) #1 said medication orders are faxed to the pharmacy and are usually delivered on the next scheduled delivery. She said that the pharmacy routinely makes deliveries to the facility twice a day, once on 7:00 A.M. to 3:00 P.M. shift, and once on the 3:00 P.M. to 11:00 P.M. shift. She further said that the pharmacy will also make a delivery on the 11:00 P.M. to 7:00 A.M. shift if needed. She said a physician's orders [REDACTED].#156 on 5/14/18 at 5:00 P.M., however, the medication was not received from the pharmacy until 5/15/18 at 4:45 P.M Therefore the resident did not receive the pain medication [MEDICATION NAME] until 5/15/18 at 4:50 P.M She further said that the Physician should have been called when the [MEDICATION NAME] was not delivered on the first delivery after the order was sent to the Pharmacy. No further documentation was found or provided to the surveyor that the Physician or Pharmacy had been contacted regarding the delay in receiving the medication. During an interview with the Director of Nurses on 05/23/18 3:25 P.M., she said there were no specific times that the pharmacy makes deliveries to the facility, but they do deliver on days, evenings, and nights. She further said the pharmacy will make additional deliveries if needed.

Based on record review and interviews, the facility failed to follow the Resident's plan of care relative to fall preventions, dysphagia recommendations and bowel medication for 4 Residents (#4, #5, #9 and #13) of a total sample of 21 Residents. Findings include: 1. For Resident #4, the facility failed to follow the plan of care addressing falls to prevent the resident from falling. Resident #4 was admitted to the facility 4/2011 with [DIAGNOSES REDACTED]. Review of the resident's Potential For Injury Care Plan related to a history of falls, dated 4/18/12, included the following interventions: -Motion sensor alarm at foot of bed, -Pressure alarm in bed, -Clip alarm, -Blue floor mat, -Bed in lowest position and positioned against the wall. Review of the Nurse's Note, dated 6/28/12 indicated the resident experienced an unwitnessed fall from the bed in his/her room at 9:00 P.M. The resident was found lying on a floor mat next to the bed. No injuries were noted. The Event Investigation Report of 6/28/12, indicated the alarms did not sound at the time of the fall. The alarm was not properly utilized per care plan. Review of the 6/28/12 Certified Nursing Assistant (CNA) Alarm Check Sheets indicated that the 3:00-11:00 P.M. shift did not initial that the resident's alarms were in place and functioning. The Care Plan update included a new intervention to move the resident's bedroom closer to the nurse's desk for increased visibility by staff (staff unable to provide exact date of room change). Review of the Nurse's Note, dated 9/22/12, indicated that Resident #4 fell out of bed at 9:30 P.M. The resident sustained [REDACTED]. The resident was sent to the hospital for evaluation, and received sutures to a 4.0 centimeter laceration on the forehead. There was also a question of a nasal fracture of indeterminate age. The Event Investigation Report of 9/22/12 indicated the floor mat was not in use (it was standing up against the wall, and not on the floor next to the bed per care plan). This report also indicated the pressure alarm did not sound at the time of the fall per care plan. Review of the 9/22/12 CNA's Alarm Check Sheet indicated that at 9:00 P.M., the CNAs did not initial (per CNA care card) that Resident #4's alarms were in place and functioning. On 10/2/12 at 11:45 A.M., Resident #4 was observed sitting in a wheelchair with a Velcro alarm seatbelt in place. Evident was a scabbed the left eyebrow and a bruised area below the left eye. During interview with the Director of Nursing (DON) on 10/3/12 at 1:45 P.M., she stated that the Resident's alarms were in place, but did not sound at the time of the falls on 6/28/12 and 9/22/12. She said that relative to the fall of 9/22/12, the CNA left the resident in bed unattended to get a bed sheet from the hallway. The DON also said the CNA did not place the floor mat down, next to the bed, before leaving the resident's bedside. 2. For Resident #9, the facility failed to follow the physician's orders [REDACTED]. Resident #9 was admitted to the facility 10/2007. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. (cubic centimeters) to 30 cc. daily. The 9/2012 MAR indicated [REDACTED]. at 9:00 A.M. daily, from 9/1/12 through 9/30/12. [MEDICATION NAME] 30 cc. po daily was not administered as ordered. The 10/2012 MAR indicated [REDACTED]. (and not 30 cc. as ordered) at 9:00 A.M. daily on 10/1 and 10/2/12. During an interview with Unit Manager #1, on 10/3/12 at 11:40 A.M., he said that the physician's orders [REDACTED]. He said that the resident did not receive the increased dose of [MEDICATION NAME] as ordered by the Physician on 9/18/12. 3. For Resident #5, the facility failed to follow the SLP (Speech Language Pathologist) recommendations as indicated on 6/21/12, to encourage the resident during meals, to take small bites of food, small sips of liquids, and to alternate solids and liquids. Resident #5 was admitted to the facility in 3/2011, and readmitted in 6/2012 with [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of a (MDS) Minimum Data Set Assessment Assessment of 5/7/12 indicated that the Resident had moderately impaired vision, severely impaired short and long term memory as evidenced by scoring 5 of 15 on the (BIMS) Brief Interview for Mental Status Assessment, and required supervision with setup help only for eating. Review of a nursing note dated 6/10/12 indicated that the Resident was admitted to the hospital due to positive guiac (blood in the stool), and bilateral rhonchi (coarse rattling) heard in the Resident's lungs. On 6/20/12 at 5:40 P.M., the Resident returned from the hospital with [DIAGNOSES REDACTED]. On 6/21/12, there was a plan of care update posted for the Resident regarding his/her diet and feeding strategies by the SLP (Speech Language Pathologist). The change in the plan of care posting consisted of a Puree/Nectar Thick Liquid Diet with the following strategies for feeding: small bites; small sips; and to alternate solids and liquids. The Resident received Speech Therapy from 6/21/12 through 7/19/12, at which time the resident was discontinued from therapy. Review of the (MDS) Minimum Data Set Assessment Assessment of 7/18/12 indicated that the Resident's short/long term memory status declined, and the resident now scored 3 of 15 on the (BIMS) Brief Interview for Mental Status Assessment, and required extensive assistance/one person physical assist with eating. Review of the Discharge Summary dated 7/24/12 indicated that the Resident was discharged with recommendations for pureed solids with honey thickened liquids. The SLP also indicated that the Resident followed safe swallowing protocol and strategies with moderate cues at least 80% of the time during therapy. On 10/3/12 at 8:35 A.M., the surveyor observed Resident #5 eating scrambled eggs. Nurse #5 stated the Resident had already eaten the cream of wheat cereal. Nurse #5 indicated the Resident could eat by him/her self after set up; despite the strategies initiated by the SLP on (6/21/12), to take small bites of food, small sips of liquids, and to alternate solids and liquids. During discussion on 10/3/12 at 10:00 A.M., the SLP stated to the surveyor that the (6/21/12) Care Plan Update Strategies were still in effect when Resident #5 was discharged from Speech Therapy on (7/24/12). On 10/3/12 at 10:05 A.M., Unit Manager #1 said that the resident should have had a Certified Nursing Assistant sitting with the Resident during the breakfast meal providing cues for the small bites of pureed food, alternating with the honey thickened liquids. 4. For Resident #13, the facility failed to follow the Resident's Potential for Injury care plan, regarding a clip alarm. Resident #13 was admitted to the facility in 3/11 with [DIAGNOSES REDACTED]. The Potential for Injury care plan, dated 4/12/12, included an intervention for a clip alarm while in wheelchair. Review of the nurse's note and the Unusual Event Report, dated 4/30/12, indicated the Resident was found crawling on hands and knees in the doorway. The clip alarm was attached to the Resident's right shoulder, but did not sound because it was in the off position. Review of the nurse's note and Unusual Event Report, dated 7/23/12, indicated the resident was found on his/her knees in front of his/her wheelchair. The Resident did not have a clip alarm on per plan of care. During an interview with the DON on 10/5/12 at 11:15 A.M., she said that both times the resident fell on [DATE] and 7/23/12 the clip alarm was not being utilized per the plan of care. Please refer to F323.

Based on record review, observations, and staff interviews, the facility failed to provide effective interventions to prevent accidents for 2 (#4 and #13) of 9 applicable residents with falls, out of a total sample to 21 residents. Findings include; 1. For Resident #4, the facility failed to utilize effective interventions to avoid injury. Resident #4 was admitted to the facility 4/2011 with [DIAGNOSES REDACTED]. Review of the Resident's Potential For Injury Care Plan related to a history of falls and poor safety awareness, dated 4/18/12, included the following interventions: -Motion sensor alarm at foot of bed, -Pressure alarm in bed, -Clip alarm, -Blue floor mat, -Bed in lowest position and positioned against the wall. Review of the 6/2012 CNA (Certified Nursing Assistant) flow sheets indicated the Resident required physical assistance of two staff members for transfers, and was completely dependent on staff for bed mobility. Review of the Fall Risk Evaluation of 6/28/12 indicated the Resident was at high risk for falls with a score of 16. A score of 10 or more indicates a high risk for falls. Review of the clinical record indicated the resident experienced an unwitnessed fall from the bed in his/her room, on 6/28/12 at 9:00 P.M. The resident was found lying on a floor mat next to the bed. No injuries were noted. The Event Investigation Report of 6/28/12 indicated the alarms did not sound at the time of the fall. Review of the 6/28/12 CNA's Alarm Check Sheet indicated that the 3:00-11:00 P.M. shift did not initial that the resident's alarms were in place and functioning. The Care Plan update included a new intervention of moving the resident's bedroom closer to the nurse's desk for increased visibility by staff (staff unable to provide exact date of room change). The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated severe cognitive impairment as evidenced by a low BIMS (Brief Interview for Mental Status) score of 3 out of a total possible score of 15. The MDS Assessment also indicated the resident required total assistance of two for bed mobility and required extensive assistance from two staff for transfers. This assessment indicated the resident sustained [REDACTED]. Review of the Fall Risk Evaluation of 9/22/12 indicated the resident was at high risk for falls with a total score of 18. Review of the clinical record indicated that Resident #4 had experienced an unwitnessed fall from the bed in his/her room, on 9/22/12 at 9:30 P.M. The resident was found lying on his/her left side on the floor beside the bed. The resident was found to have a cut to left forehead and nose, and the nose was bleeding. The resident was sent to the hospital for evaluation. At the hospital, the resident received absorbable sutures to a 4.0 cm. (centimeter) wound in the forehead (there was no indication in the clinical record how many sutures were placed). The resident also received a CT (Computerized Tomography) of the brain/head and face on 9/22/12. The CT findings included, a 7.0 mm. (millimeter) forehead hematoma (a collection of blood under the skin) with soft tissue swelling, and a nasal septal irregularity compatible with age indeterminate fracture. The Event Investigation Report of 9/22/12, indicated the floor mat was not in use (it was standing up against the wall, and not on the floor next to the bed per care plan). This report also indicated the pressure alarm did not sound at the time of the fall. Review of the 9/22/12 CNA's Alarm Check Sheet revealed that at 9:00 P.M., CNAs did not initial that Resident #4's alarms were in place and functioning. The Care Plan update of 9/22/12 included, "Education with CNA's on Care Card/Care Plan for safety and 15 minute safety checks at all times." On 10/2/12 at 11:45 A.M., Resident #4 was observed sitting in a wheelchair with a Velcro alarm seatbelt in place. Evident was a scabbed the left eyebrow and a bruised area below the left eye. On 10/3/12 at 9:30 A.M., Resident #4 was observed sitting in a wheelchair wearing Velcro alarm seatbelt. The resident was quiet with the eyes closed. The scabbed area above left eyebrow and bruised area below left eye remained visible. During interview, on 10/3/12 at 2:00 P.M., Resident #4's family member verbalized disappointment when learning of the circumstances which led to the Resident's fall. During interview with the Director of Nursing (DON) on 10/3/12 at 1:45 P.M., she stated that the Resident's alarms were in place, but did not sound at the time of the falls on 6/28/12 and 9/22/12. She said that relative to the fall of 9/22/12, the CNA left the resident in bed unattended to get a bed sheet from the hallway. The DON also said the CNA did not place the floor mat down, next to the bed before leaving the resident's bedside. She said that the CNA did not follow the resident's care card relative to the placement and proper functioning of the safety devices to prevent the falls. 2. For Resident #13, the facility failed implement interventions to reduce the risk for falls. Resident #13 was admitted to the facility in 3/11 with [DIAGNOSES REDACTED]. Review of the Resident's Potential for Injury care plan, dated 4/12/12, included the intervention to apply a clip alarm when in the wheelchair. Review of the nurse's note and the Unusual Event Report, dated 4/30/12, indicated the Resident was found crawling on hands and knees in the doorway, said he/she couldn't find the call light, and needed to get the nurse's attention. The clip alarm was attached to the Resident's right shoulder but did not sound because it was in the off position. Review of the Quarterly MDS Assessment, dated 5/16/12, indicated the Resident was cognitively impaired, required extensive assist of one for transfers and ambulation, and had two or more falls without injury. Review of the Fall Risk Evaluation, dated 5/20/12, indicated a score of 21. A total score of 10 or above indicates a high risk for falls. Review of the nurse's note and the Unusual Event Report, dated 7/23/12, indicated the Resident was found on his/her knees in front of the wheelchair while attempting to go the the bathroom. The clip alarm was not attached to his/her shirt. On 10/3/12 at 10:00 A.M., the surveyor observed Resident #13 in a Broda Chair, with a tray, having breakfast with a CNA providing assistance. The clip alarm was not attached because it had been discontinued. During an interview with the DON on 10/5/12 at 11:15 A.M., she said for both falls, the interventions put into place to prevent the Resident from falling were not implemented.