Every finding on record at Hadley Pointe Nursing Rehab & Care

Based on observation, interview, and record review, the facility failed to ensure that care and treatment consistent with professional standards of practice for Congestive Heart Failure (CHF - a condition in which the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) was provided for one Resident (#1) out of a total sample of 19 residents. Specifically, the facility failed to obtain ordered weekly weights, failed to conduct respiratory and fluid status assessments consistent with the facility's own Heart Failure Protocol and Physician orders, and failed to notify the Nurse Practitioner (NP) when ordered weights were not obtained for Resident #1, a Resident admitted in March 2026 with a known diagnosis of CHF - resulting in an undetected 19.6 lb. weight gain over approximately 30 days, an unrecognized exacerbation of CHF symptoms including persistent cough and nausea, and the need for escalated pharmacological intervention with an increased Lasix dose and additional diagnostic laboratory orders. Findings include:Review of the facility policy titled Weight Monitoring Guidelines Policy, dated as revised on 10/2025, indicated the following:-Ensure routine monitoring of resident weight and nutritional status, identification of significant changes, timely intervention, and compliance with federal and state regulations.-Obtain admission weight within 24 hours, then weekly x4 (unless otherwise indicated and/or ordered by the physician)-Weekly weights for at-risk residents as recommended by the Registered Dietician (RD) or the Physician-Documentation: weights entered in EMR/weights and VS section of PCC Review of the Heart Failure Protocol, created 11/17/25, indicated:-This protocol provides evidence-based clinical guidelines to help clinical staff and practitioners develop and implement a patient-centered treatment plan for the patient with a diagnosis of heart failure.- Organize and Develop a Patient-Centered Plan of Care-Develop an individualized plan of care including, but not limited to:>medication management>fluid balance (e.g., measure weights routinely, document accurately and track to determine cause)>respiratory status (e.g., evaluate lung sounds, respiratory rate, presence of SOB and/or cough, pulse oximetry, restlessness, cognitive changes)-staff education on HF (Heart Failure) monitoring and management should be provided regularly and tailored to all levels of healthcare providers.-Additional considerations>CNAs-Accurately weigh and daily weights-General recommendations>Patients with HF should receive weight assessments, vital signs, nursing assessment of signs and symptoms, and education consistent with HF guidelines and goals of care. Resident #1 was admitted to the facility in March 2026 with diagnoses including Congestive Heart Failure (CHF), Pneumonia and Asthma. Review of the hospital discharge documentation indicated Resident #1 had an active diagnosis of CHF. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1:-was cognitively intact with a Brief Interview of Mental Status (BIMS) assessment score of 15 out of 15.-had no rejection of care behaviors.-has a diagnosis of Heart Failure.-weight of 232 lbs. (pounds) During an interview on 4/21/26 at 8:58 A.M., Resident #1 said that he/she had not felt well with a persistent cough for a few weeks. Resident #1 said that his/her family was concerned about CHF because he/she had CHF before and it feels similar. Resident #1 said the staff weighed him/her on 4/16/26 for the first time since admission and he/she had gained 20 lbs. (19.6 lbs.). Resident #1 said he/she was concerned about the weight gain and felt like his/her condition had worsened since admission. Resident #1 said he/she had been taking Lasix at home as needed for weight gain but had not received any Lasix since admission to the facility. Review of the Nurse Practitioner Progress Notes for Resident #1 dated 3/23/26, indicated:-hypertensive heart disease with heart failure-diagnosis of chronic diastolic heart failure-has no upper respiratory infections, cough or wheezing at the time of the assessment-plan of care was to continue Lasix 20 mg (milligrams) by mouth daily as needed (PRN) and to monitor fluid and respiratory status, BP (blood pressure), labs and weights Review of the Nurse Practitioner Progress Note for Resident #1 dated 4/13/26, indicated:-symptoms of upper respiratory symptoms including wheezing and coughing-diminished breath sounds bilaterally, with bronchospastic coughing and inspiratory wheezes.-diagnosis of Acute Bronchitis-start Duonebs 3 ml. (milliliters) every six hours for three days-start Mucinex 600 mg (milligrams) twice daily for seven days Review of the Physician orders for March 2026 and April 2026 indicated the following for Resident #1:-Weigh every day shift every Mon (Monday) for 4 weeks, initiated 3/16/26.>3/16/26: recorded weight of 231.6 (weight referenced in the 3/21/26 MDS)-Lasix 20 mg daily by mouth daily PRN for edema, initiated 3/15/26 -Weigh every day shift every 1 month(s) starting on the 1st, initiated 4/1/26 (not done).-Obtain weight one time only for weight for 1 day, initiated 4/8/26 (not done)-Lasix 40 mg tablet. Give 40 mg by mouth in the morning for CHF for 5 days, initiated 4/18/26. Review of the medical record failed to indicate that weights were obtained as ordered on the following dates (documentation on the MARs indicated code - 9 (Other/ See Nurse Notes):-3/23/26-3/30/26-4/1/26-4/6/26-4/8/26 Review of the Weight Summary for Resident #1 indicated the following:3/16/26: 231.6 lbs. - obtained via mechanical lift scale4/16/26: 251.2 lbs. - mechanical lift scale (19.6 lb. weight gain in 30 days)4/21/26: 250.4 lbs. - mechanical lift scale4/22/26: 251.2 lbs. - mechanical lift scale (repeated for accuracy) During an interview on 4/21/26 at 9:06 A.M., Nurse #8 said Resident #1 had been coughing for about a week and started feeling nauseous. Nurse #8 reviewed Resident #1's weight summary record and said Resident #1 was only weighed twice since admission, had a 20 lb. (19.6 lb.) weight gain and Nurse # 8 did not know why. Nurse #8 said she documented code - 9 on the MAR, because Resident #1 would often refuse care. Nurse #8 said any refusal of care should be documented on the MAR, explained in a progress note, and reported to the Provider but she was unsure if this had occurred. Nurse #8 said she was unsure if Resident #1 had CHF. Nurse #8 then reviewed the Resident's diagnosis list and found a diagnosis of CHF. Nurse #8 said that if a resident has a diagnosis of CHF, they should have lung assessments and weights done daily. Nurse #8 said she did not recall listening to Resident #1's lungs prior to this past weekend. Nurse #8 said the Resident had an order for Lasix 20 mg daily PRN for edema, but he/she had not received any Lasix since admission and there was no order for Nurses to monitor for edema but there should have been. During an interview on 4/21/26 at 11:45 A.M., CNA #8 said that she is familiar with Resident #1 and that the Resident will sometimes choose to stay in bed but had not refused being weighed. CNA #8 said she was not aware of any weight refusals from Resident #1 and was not sure how often he/she gets weighed. CNA #8 said Resident #1 agreed to get weighed today. During an interview on 4/21/26 at 9:32 A.M., Resident #1 said he/she did get weighed on admission to the facility but did not recall being asked by staff to obtain another weight until he/she was weighed on 4/16/26. Resident #1 said he/she often chooses to stay in bed but was not asked about getting out of bed for a weight. Resident #1 said when he/she found out that he/she had gained 20 lb. (19.6 lbs.), he/she did ask about getting Lasix, because he/she used it at home for weight gain. Review of the Nurse Practitioner Progress Note for Resident #1 dated 4/21/26, indicated:-Resident was seen for follow-up on cough.-Weight of 250.4 lbs.-Chronic diastolic heart failure with 20 lb. (19.6 lb.) weight gain in one month-Continue Furosemide (Lasix) 40 mg daily-Change weights to daily-Order BMP (Basic Metabolic Panel) and BNP (B-type natriuretic peptide [used to diagnose or evaluate heart failure]) Friday -Monitor fluid and respiratory status, labs and weights During an interview on 4/21/26 at 11:38 A.M., the Nurse Practitioner (NP) said she was not made aware that Resident #1 had not been weighed since admission and that he/she had refused any weights. The NP said Resident #1 had a history of refusals of medications but to her knowledge this did not include refusals of weights. The NP said she expected the staff to obtain weights weekly according to the Physician's order and update her if that did not occur. The NP said she had not been made aware of Resident #1 refusing weights and if she had been made aware, she would have provided education and additional follow-up to Resident #1. The NP said that for any Resident with CHF she expects the facility to follow the CHF protocol and obtain respiratory assessments including lung sounds and pulse oximetry. The NP said that she has been following Resident #1's respiratory status due to a recent bronchitis and performed a follow-up visit on 4/16/26 and then realized the Resident had not been weighed since admission, which resulted in her asking for a weight and then discovered the 20 lb. (19.6 lb.) weight gain had occurred and further resulted in a new order for Lasix. During an interview on 4/21/26 at 11:59 A.M., Unit Manager (UM) #1 said a resident with CHF should have daily weights and respiratory assessments including lung sounds to determine fluid balance. The UM said any refusals of care including weights, should have been written as a Nurse's note and reported to the Provider. UM #1 said there was no evidence in the progress notes that Resident #1 had refused to be weighed or that the NP was updated regarding any refusals of weights. UM #1 said a Resident with CHF should have daily weights and lung assessments. UM #1 said that any refusals of care should be written in the Nurse's notes and then reported to the Provider. During an interview on 4/21/26 at 4:35 P.M., the Director of Nursing (DON) said for Resident #1, the nursing staff should have met with the NP upon the Resident's admission to verify the correct orders were in place for a Resident with CHF, but they did not. The DON said the facility did not properly assess and monitor Resident #1 for CHF, did not develop a CHF plan of care, did not provide fluid balance monitoring including weights/edema monitoring and could not provide evidence of respiratory status monitoring including lung sounds. The DON said had the facility properly assessed Resident #1 for CHF upon admission, the weight gain could have been avoided. During a follow-up interview on 4/22/26 at 10:48 A.M., the DON said the facility did not obtain the ordered weights and the NP should have been updated. The DON said had the facility followed their CHF protocol and had the NP been updated, Resident #1 could have avoided a 20 lb. (19.6 lb.) weight gain. Please Refer to F726

Based on observation, record review, and interview, the facility failed to ensure that sufficient nursing staff were available to provide care and services to attain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with the facility assessment.Specifically, the facility failed to ensure that sufficient Certified Nurse Aides (CNAs) were available to provide personal care and services timely to meet the needs of the facility residents, the facility also failed to ensure that call lights were answered timely, and that CNAs were scheduled based on the acuity level of residents. Findings include:Review of the Facility Assessment, dated February 2026, indicated the following:-Acuity Level:>Average Daily Census was 87>80% of residents required assist of 1-2 staff for dressing, and 11% were dependent on staff>79% of residents required assist of 1-2 staff for toileting, and 11% were dependent on staff>66% of residents required assist of 1-2 staff for eating, and 22% were dependent on staff>72% of residents utilized a chair for mobility most of the time-Direct Care Staffing Plan:Day shift (7:00 A.M. to 3:00 P.M.):1st Floor- 10:1 resident/certified nursing assistant (CNA) ratio2nd Floor- 10:1 resident/CNA ratio2nd/ Evening Shift (3:00 P.M. to 11:00 P.M.):1st Floor- 10:1 resident/CNA ratio2nd Floor- 10:1 resident/CNA ratio3rd/ Night Shift (11:00 P.M. to 7:00 A.M.):1st Floor- 20:1 resident/CNA ratio2nd Floor- 17:1 resident/CNA ratioThe Facility Assessment did not include a minimum standard of staffing for hours per patient day (HPPD - staffing hours per resident per day which is the total number of hours worked by each type of staff divided by the total number of residents) of direct nursing care provided to ensure the residents' health and safety. Review of the Nursing and CNA Schedules and Facility Census from 3/22/26 - 4/22/26 indicated the following shifts were staffed below the staffing ratio identified in the facility assessment:3/21/26 - Total census: 86, 7 CNA's worked Day Shift (1.5 less than required), 5 CNA's worked Evening Shift (3.5 less than required), 3 CNA's worked Night Shift (2 less than required).3/22/26- Total census: 86, 6 CNA's worked Day Shift (2.5 less than required), 8 CNA's worked Evening Shift (0.5 less than required)3/28/26- Total census: 88, 8 CNA's worked Day Shift(1 less than required)3/30/26- Total census: 91, 6 CNA's worked Day Shift. (3 less than required), 5 CNAs worked Night Shift (1 less than required).3/31/26- Total census: 89, 7 CNA's worked Day Shift (1.5 less than required), 4 CNA's worked Night Shift (1.5 less than required).4/1/26- Total census: 90, 5 CNA's worked Day Shift (4 less than required), 8 CNA's worked Evening Shift (1 less than required), and 5 CNA's worked Night Shift (0.5 less than required).4/4/26- Total census: 92, 7 CNA's worked Day Shift (2 less than required), 6 CNA's worked Evening Shift (3 less than required), and 4 CNA's worked Night Shift (1.5 less than required).4/5/26- Total census: 92, 6 CNA's worked Day Shift (3 less than required), 7 CNA's worked Evening Shift (2 less than required), 5 CNA's worked Night Shift (0.5 less than required).4/6/26- Total census: 90, 7 CNA's worked Day Shift (2 less than required), 8 CNA's worked Evening Shift (1 less than required).4/7/26- Total census: 90, 7 CNA's worked Day Shift (2 less than required), 8 CNA's worked Evening Shift (1 less than required), 4 CNA's worked Night Shift (1.5 less than required).4/9/26- Total census: 91, 8 CNA's worked Day Shift (1 less than required), 3 CNA's worked Night Shift (2.5 less than required).4/10/26- Total census: 91, 7 CNA's worked Day Shift (2 less than required), 5 CNA's worked Night Shift (1 less than required).4/20/26- Total census: 91, 7 CNA's worked Day Shift (2 less than required), 5 CNA's worked Night Shift (1 less than required). During the Initial Pool Resident Interviews on 4/15/26 from 8:23 A.M. to 11:51 A.M., the following was said relative to staffing:-Resident #50 said that the facility did not have enough help at times, including overnight and weekends, and that he/she has waited for hours for assistance with incontinence.-Resident #104 said he/she had waited 1-2 hours for assistance at times when he/she rang their call light and the previous night he/she requested pain medication at 4 A.M. and did not receive the pain medication until 6:30 A.M. (2.5 hours later). During the Resident Council Meeting held on 4/15/26 at 2:08 P.M., the following was said relative to staffing:-7 out of 15 residents said they had gone over a week without a shower.-11 out of 15 residents said they did not receive help within 10 minutes of asking for help.-5 out of 15 residents said they had waited more than 15 minutes to receive help on a regular basis.-Between the hours of 8:45 P.M. to 11:30 P.M., one resident reported waiting more than 30 minutes and another resident said he/she frequently observed a lot of call lights on at once after suppertime.-Staff report to residents that they are frequently short staffed.-Resident council had brought up these staffing issues in March 2026 and were told that the facility was working to hire people.-Resident council had not received any updates about staffing or hiring plans. During an interview on 4/17/26 at 12:56 P.M., CNA #1 said that the current staffing levels are not typical and that it is all hands on deck because of state survey. CNA #1 said the facility is frequently short staffed primarily due to call outs which makes it difficult to provide care in a timely manner when there are not enough CNAs. During a follow-up interview on 4/21/26 at 11:53 A.M., CNA #1 further said that more staff on the Night Shift are needed on the 1st floor unit and it is a lot to deal with care and behaviors at times. CNA #1 further said if staff are new, they often become overwhelmed as residents have more behaviors overnight and the majority of residents on the unit are incontinent. During an interview on 4/21/26 at 12:07 P.M., CNA # 2 said that she felt the facility did not have enough staff in the past 6 months and that happens across all shifts. CNA #2 said that the facility schedules staff but there are a lot of call outs and that families have complained about not enough staff. During an interview on 4/21/26 at 12:17 P.M., Nurse #8 said that sometimes the facility has been short CNA staff. Nurse #8 said when call outs happen, the facility has a nurse on-call who would attempt to obtain staff to fill the spot. Nurse #8 said that often the call out shift remains unfilled and they will try to pull staff from the other unit if needed. Nurse #8 said at one point last week, there were only 3 CNAs on a Day Shift on the second floor Unit. Nurse #8 said that management is aware that the units run short of staff very often. Nurse #8 said that about once a week she sees residents waiting with call lights on and that families and residents have approached her at least once regarding wait times to receive care. During an interview on 4/21/26 at 4:30 P.M., the Scheduler said that she had been in the role since March 2026. The Scheduler said she staffs the facility according to the facility census and based on the acuity level of residents on the units as the level of care and needs may fluctuate at times. The Scheduler said that she typically staffs the units with a ratio of 10 residents to 1 CNA on the Day and Evening Shifts. The Scheduler said recently they increased the number of CNAs on the Night Shift as the acuity on the first floor Unit had also increased. The Scheduler said that she will book extra CNAs to deal with the pattern of call outs daily. The Scheduler further said that when call outs occur, she will attempt to find extra staff, put a messaging request in the electronic staffing system, and Scheduler will call staff directly to fill the opening. The Scheduler said the weekend of April 4th - 6th was the Easter Holiday weekend and there were a lot of call outs. During an interview on 4/22/26 at 7:44 P.M., the Administrator said that the expectation was if staff call out, they must do so 2 hours prior to their shift. The Administrator said that the prior culture of the facility was that some staff had a pattern of call outs. The Administrator said this is being addressed with Human Resources via discipline process and holding recent staff meetings addressing the call out process. The Administrator said that he uses an all hands on deck approach with other staff assisting such as Rehabilitation Staff or others who are cross trained.

Based on observation, interview, and record review, the facility failed to maintain current employee records to ensure that licensed nurses and other personnel have demonstrated the knowledge, competencies, and skill sets to provide care and respond to each residents' plan of care for one out of five licensed nursing staff employee files reviewed.Specifically, the facility failed to provide education and assess for nursing staff competency of Congestive Heart Failure (CHF) protocol initiated on 11/17/25, resulting in non-implementation of the CHF protocol for Resident #1 resulting in a 19.6 lb. (pound) weight gain requiring pharmacological intervention. Findings include: Review of the facility policy titled Competency Evaluation, dated November 2025, indicated the following: -The knowledge and skill required among staff to meet residents' needs are determined through the facility assessment process. -Evaluating competency of staff is accomplished though the facility's training program. -Initial competency is evaluated during the evaluation process. An employee remains on orientation until all competencies are verified. -Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. -A variety of methods may be used to evaluate learning and/or skills competency. Examples include but are not limited to: a. A lecture of demonstration with return by the employee b. A pre- and post-test for the learning ability c. Direct observation of the employee's ability to demonstrate use of tools, devices, or equipment. d. Direct observation of the employee's ability to perform specific tasks. -Checklists are used to document training and competency evaluations. -Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to Human Resources Director for placing in the employee's personnel file. Review of the Facility Assessment, dated February 2026, indicated the following: -The facility accepted residents with diseases and conditions including but not limited to: >Heart/Circulatory system: Congestive Heart Failure.Hypertension.Peripheral Vascular Disease.Deep Venous Thrombosis. -The facility provided residents with the following support and care needs: >Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds) >Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD). -Staff training/education and competencies: >Training and education to be given to staff during job specific orientation and annually.On the job training is done whenever there is something identified as an immediate need or lack of education. This includes demonstration, verbal training and policy and procedure education . Competencies for Licensed Nurses upon hire and annually: . >Cardiovascular assessment . >Respiratory Assessment . -Training for License Nurses upon hire and thereafter only as indicated/required: . >Assessment of the resident- cardiac, respiratory, gastrointestinal, genitourinary, skin, wound . >Change in resident condition- assessment, notification (SBAR), and documentation . >Reporting and documentation- skilled documentation, INTERACT forms, SBAR communication Review of the Heart Failure (HF) Protocol, created 11/17/25, indicated: -This protocol provides evidence-based clinical guidelines to help clinical staff and practitioners develop and implement a patient-centered treatment plan for the patient with a diagnosis of heart failure. -Organize and Develop a Patient-Centered Plan of Care -Develop an individualized plan of care including, but not limited to: >medication management >fluid balance (e.g., measure weights routinely, document accurately and track to determine cause) >respiratory status (e.g., evaluate lung sounds, respiratory rate, presence of SOB and/or cough, pulse oximetry, restlessness, cognitive changes) -staff education on HF (Heart Failure) monitoring and management should be provided regularly and tailored to all levels of healthcare providers. -Additional considerations >CNAs -Accurately weigh and daily weights -General recommendations >Patients with HF should receive weight assessments, vital signs, nursing assessment of signs and symptoms, and education consistent with HF guidelines and goals of care. Resident #1 was admitted to the facility March 2026 with diagnoses including Congestive Heart Failure (CHF), Pneumonia and Asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) Assessment score of 15 out of 15. -had no rejection of care behaviors. -has a diagnosis of Heart Failure. -weight of 232 lbs. (pounds). Review of the Nurse Practitioner (NP) Progress Notes for Resident #1 dated 3/23/26, indicated: -Hypertensive heart disease with heart failure -Diagnosis of chronic diastolic heart failure -Plan of care was to Continue Lasix 20 mg (milligrams) by mouth daily as needed (PRN) and to monitor fluid and respiratory status, BP, labs and weights Review of the Medical Record for Resident #1 failed to indicate the following were assessed by the nursing staff: -monitoring of fluid balance and circulation -Respiratory Status (lung sounds, presence of shortness of breath and/or cough) -Circulation (lower extremities for color, pulses, edema)- -weights Review of Weight Summary for Resident #1 indicated: 3/16/26: 231.6 lbs. – obtained via mechanical lift scale 4/16/26: 251.2 lbs. - mechanical lift scale (19.6 lb. weight gain in 30 days) During an interview on 4/21/26 at 8:58 A.M., Resident #1 said that he/she had not felt well with a persistent cough for a few weeks. Resident #1 said that his/her family was concerned about CHF because he/she had CHF before and it feels similar. Resident #1 said the staff weighed him/her on 4/16/26 for the first time since admission and he/she had gained 20 lbs. (19.6 lbs.) Resident #1 was concerned about his/her weight gain and felt like his/her condition had worsened since admission. Resident #1 said he/she had been taking Lasix at home as needed for weight gain but had not received any Lasix since admission to the facility. During an interview on 4/21/26 at 11:38 A.M., the Nurse Practitioner (NP) said that for any resident admitted with a diagnosis of CHF, she expects the facility to follow the CHF protocol which includes respiratory assessments, weights and fluid monitoring. During an interview on 4/21/26 at 9:06 A.M., Nurse #8 said Resident #1 had been coughing for about a week. The surveyor and Nurse #8 reviewed Resident #1's weight summary and Nurse #8 said Resident #1 had only been weighed twice since admission and had a 20lb (19.6 lb.) weight gain and did not know why. Nurse #8 said she was unsure if Resident #1 had CHF but then reviewed the diagnosis list and found the Resident has a diagnosis of CHF. Nurse #8 said that if a resident has a diagnosis of CHF, they should have lung assessments and weights done daily. Nurse #8 said she did not recall listening to Resident #1's lungs prior to this past weekend. Nurse #8 said Resident #1 had an order for Lasix 20 mg (milligrams) daily as needed for edema but had not received any Lasix medication since admission. Nurse #8 also said that there was no order to monitor for edema but there should have been. During an interview on 4/21/26 at 4:35 P.M., the Director of Nursing (DON) said for Resident #1 the nursing staff should have met with the NP upon admission to verify the correct orders were in place for a Resident with CHF but did not. The DON said that the facility did not follow and properly assess and monitor Resident #1 for CHF, did not develop a CHF plan of care, did not provide fluid balance monitoring including weights/edema monitoring and could not provide evidence of respiratory status monitoring including lung sounds. The DON said that had the facility properly assessed Resident #1 for CHF upon admission, the weight gain could have been avoided. The DON said that she could not provide evidence that education and competencies had been completed when the facility implemented the CHF protocol in November 2025.

Based on records reviewed and interviews, the facility failed to ensure the newly hired employees' records contained evidence of the 2025 - 2026 COVID-19 vaccination for four employees (CNA #6, Nurse #4, Nurse #5, and CNA #7) out of five newly hired employees, and that five Residents (#65, #74, #7,#4 and #94) out of five residents reviewed for vaccinations, contained evidence that the 2025-2026 COVID-19 vaccination had been offered, received or declined, placing the staff and residents at increased risk of becoming infected with the Coronavirus disease (COVID-19 - infection caused by the SARS-CoV-2 virus).Specifically, the facility failed to ensure that:employees' records for CNA #6, Nurse #4, Nurse #5, and CNA #7, contained evidence of the 2025-2026 COVID-19 vaccination or that the newly hired employees were offered the most up to date (2025-2026) COVID-19 vaccine when he/she was eligible.Resident #65, #74, #7, #4 and #94's medical records contained evidence of the 2025-2026 COVID-19 vaccination or that the Residents/Resident Representatives had been offered the most up to date COVID-19 vaccine when they were eligible. Findings include:Review of the Centers for Disease Control and Prevention (CDC) guidance for Health Care Providers, dated 11/4/25, indicated but was not limited to the following: -The CDC recommends the 2025-2026 COVID-19 vaccine for people ages 6 months and older. -.some people may be at increased risk for SARS-CoV-2 infection including healthcare workers and residents and employees in long-term care facilities. -The CDC recommends that people ages 12-[AGE] years old be administered one dose of the 2025-2026 COVID-19 vaccine for people that are unvaccinated, as well as for people who have been previously vaccinated (Administer the dose at least eight weeks after the last dose of Spikevax, Novavax, or Pfizer-BioNTech, or at least three months after the last dose of mNexspike). -The CDC recommends that people ages 65 years and older be administered two doses of the 2025-2026 COVID-19 vaccine for people that are unvaccinated, as well as for people who have been previously vaccinated: >For people that are unvaccinated, Dose 2 of the 2025-2026 COVID-19 vaccine (Spikevax, Novavax, or Pfizer-BioNTech) is recommended to be administered six months after Dose 1 (minimal interval of two months), or six months (minimum interval of three months) if mNexspike is administered. >For people who have been previously vaccinated, Dose 1 of the 2025-2026 COVID-19 vaccine (Spikevax, Novavax, or Pfizer-BioNTech) is recommended to be administered at least eight weeks after the last dose, and at least three months after the last dose if Nexspike is administered. Dose 2 of the 2025-2026 COVID vaccine (Spikevax, Novavax, or Pfizer-BioNTech) is recommended to be administered six months (minimum interval of two months) after Dose 1 of the 2025-2026 COVID vaccine, or six months (minim interval of three months) if mNexspike is administered. Review of the facility policy titled COVID-19 Vaccination, undated, included was not limited to: -Policy statement: To reduce morbidity and mortality from COVID-19, all employees and residents who have no medical contraindications and meet the criteria established by the CDC and Advisory Committee on Immunization Practices (ACIP) will be offered the COVID-19 vaccine. The facility shall provide pertinent information about the significant risks and benefits of the vaccine to employees and residents (or residents' responsible parties). -The facility will.administer the COVID-19 vaccination to eligible employees and residents. -Prior to vaccination, employees and residents (or residents' responsible parties) will be provided with a copy of the vaccine's Emergency Use Authorization (EUA) Fact Sheet, information and education regarding the risks and benefits and potential side effects of the vaccine. Provision of such education shall be documented in the employee's/resident's medical record. -Prior to vaccination, informed consent will be obtained. -Refusal of the vaccine shall be documented in the employee's/resident's medical record. 1a. Review of the employee file for Certified Nurse Aide (CNA) #6 indicated the staff member was hired on 12/5/25. CNA #6's immunization record indicated the most recent COVID-19 vaccine received was on 11/16/23. Further Review of CNA #6's employee file failed to indicate the facility had offered the staff member the 2025-2026 COVID-19 vaccine. 1b. Review of the employee file for Nurse #4 indicated the staff member was hired on 12/7/25. Nurse #4's immunization record indicated the most recent COVID-19 vaccine was received on 10/6/24. Further Review of Nurse #4's employee file failed to indicate that the facility had offered the staff member the 2025-2026 COVID-19 vaccine. 1c. Review of the employee file for Nurse #5 indicated the staff member was hired on 2/1/26. Nurse #5's immunization record indicated the most recent COVID-19 vaccine was received on 3/19/21. Further Review of Nurse #4's employee file failed to indicate that the facility had offered the staff member the 2025-2026 COVID-19 vaccine. 1d. Review of the employee file for CNA #7 indicated the staff member was hired on 2/15/26. CNA #7's immunization record indicated the most recent COVID-19 vaccine was received on 2/20/23. Further Review of CNA #7's employee file failed to indicate that the facility had offered the staff member the 2025-2026 COVID-19 vaccine. During an interview on 4/21/26 at 3:35 P.M., the Human Resources staff said the Human Resources Department was responsible for ensuring newly hired employees had the COVID-19 vaccine. The Human Resources staff said the Infection Preventionist (IP) would identify whether the newly hired staff met vaccination requirements of the facility. During an interview on 4/21/26 at 3:40 P.M., the IP said she was not familiar with the process for newly hired employees relative to COVID-19 vaccination. The IP said the facility had not offered the COVID-19 vaccine to any staff member since she assumed the role of IP. The IP said that she had not encountered any issues obtaining the 2025-2026 COVID-19 vaccine from the pharmacy. During a follow-up interview on 4/22/26 at 8:10 A.M., the IP said the expectation was that the facility offered the most up-to-date COVID-19 vaccine to all newly hired employees at the time of hire. The IP said that the newly hired employees (CNA #6, Nurse #4, Nurse #5, and CNA #7) should have been offered the most up-to-date COVID-19 vaccine and was not offered the vaccine. During an interview on 4/22/26 at 3:06 P.M., CNA #7 said the facility had not offered her the most up-to-date COVID-19 vaccine upon hire, and that she was offered the vaccine earlier today (4/22/26). During an interview on 4/22/26 at 3:13 P.M., Nurse #5 said that upon hire the facility had requested evidence of her COVID-19 vaccination status. Nurse #5 said that the facility did not offer to administer the COVID-19 vaccine to her upon hire. Nurse #5 said that the facility offered her the most up-to-date COVID-19 vaccine either the day before (4/21/26) or earlier that day (4/22/26). 2a.Resident #65 was admitted to the facility in May 2025 with diagnoses including Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD) and was over the age of 65. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65: -has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of four out of a possible 15 points. -was not up to date with the current Covid vaccine. Review of Resident #65's Immunization Report indicated the most recent COVID-19 vaccine (2023 - 2024 Booster Pfizer) was received on 8/18/22. Review of Resident #65's medical record failed to indicate that the 2025-2026 COVID-19 vaccine had been offered, declined or was contraindicated for the Resident. During an interview on 4/21/26 at 12:09 P.M, the Infection Preventionist (IP) said she was unable to find evidence that Resident #65 had been offered, received or had declined the Covid 2025 - 2026 vaccine. 2b. Resident #74 was admitted to the facility in December 2023 with diagnoses including dementia, fractures, diabetes, hypertension and was over the age of 65. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #74: -has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. - was not up to date with the Covid-19 vaccine. Review of Resident #74's Immunization Report indicated the most recent COVID-19 vaccine (COMIRNATY Pfizer Covid-19 Vaccine) was received on 11/11/24. Review of Resident #74's medical record failed to indicate that the 2025 - 2026 COVID-19 vaccine had been offered, declined or was contraindicated for the Resident. During an interview on 4/21/26 at 12:09 P.M, the Infection Preventionist (IP) said she was unable to find evidence that Resident #74 had been offered, received or had declined the Covid 2025-2026vaccine. The IP further said that based on Resident #74's immunization history he/she would be due for the 2025 - 2026 Covid-19 vaccine. 2c. Resident #7 was admitted to the facility in December 2024 and was over the age of 65. Review of the MDS assessment dated [DATE], indicated Resident #7: -has severe cognitive impairment as evidenced by a BIMS score of three out of a possible 15 points -was not up to date with the COVID-19 immunization. Review of Resident #7's clinical record indicated the following: -Immunization Report that the COVID-19 vaccine was last received on 12/12/24. -no documented evidence that the 2025 - 2026 COVID-19 vaccine was offered, received or declined. During an interview on 4/21/26 at 12:08 P.M., the IP said the Nurse would obtain COVID-19 consent on admission. The IP said once consent for the COVID-19 vaccine was obtained, she would check MIIS (Massachusetts Immunization Information System) to ensure the resident had not already received the vaccine, and if they had not received the vaccine, she would obtain orders from the Physician to administer it. The IP said there has been no difficulty with obtaining the COVID-19 vaccine from the pharmacy. The IP said Resident #7 had last received the COVID-19 vaccine in 2024. The IP further said that upon reviewing the Resident's clinical record, there was no indication that the Resident/Resident's Representative had been offered to receive, had been administered or declined the 2025-2026 COVID-19 vaccine. 2d. Resident #4 was admitted to the facility in May 2023 and was over the age of 65. Review of the MDS Assessment, dated 2/24/26, indicated Resident #4: -had severe cognitive impairment as evidenced by a BIMS score of four out of 15 possible points. -was not up to date with the COVID-19 immunization. Review of Resident #4's clinical record indicated the following: -written consent to receive the COVID-19 vaccine had been obtained on 10/16/24. -COVID-19 vaccine had been received on 10/29/24 -no documented evidence the 2025-2026 COVID-19 vaccine had been offered, received or declined. 2e. Resident #94 was admitted to the facility in June 2025 and was over the age of 65. Review of the MDS Assessment, dated 3/22/26 indicated Resident #94: -was cognitively intact as evidenced by a BIMS score of 15 out of a possible 15 points. -was not up to date with the COVID-19 immunization. Review of the Resident #94's clinical record indicated: -the Resident had been transferred out of the facility to the hospital on 4/21/26. -COVID-19 vaccine had been received on 10/19/23. -no documented evidence the 2025-2026 COVID-19 vaccine had been offered, received or declined. During an interview on 4/22/26 at 3:01 P.M., the Chief Nursing Officer said the facility would review the COVID-19 vaccination status of residents on admission and if the vaccine had been previously received, the facility would obtain evidence of this. The Chief Nursing Officer said if the COVID-19 vaccine had not been received, the facility would offer to administer it. The Chief Nursing Officer said the resident/resident representative would be educated on the COVID-19 vaccine and written consent or declination would be obtained. The Chief Nursing Officer said the 2025-2026 COVID-19 vaccine is the most up to date vaccine to be administered. During a follow-up interview on 4/22/26 at 3:54 P.M., the IP said she had focused on tracking and administering other recommended vaccines and had not focused on the 2025-2026 COVID-19 vaccine administration for the residents in the facility. The IP further said that she was not sure if the 2025-2026 COVID-19 vaccines could be administered with other vaccines. The IP said she was unable to find evidence that Residents #7, #4 and #94 had been offered to receive or had declined the 2025-2026 COVID-19 vaccine.

Based on interview, and record review, the facility failed to offer Pneumococcal and Influenza immunizations to two Residents (#65 and #4), of five applicable residents reviewed for pneumococcal and influenza immunizations, out of a total sample of 19 residents. Specifically, the facility failed to ensure that: Resident #65 was offered the updated Pneumococcal and Influenza vaccines when he/she was identified to be at high risk for pneumococcal and influenza infection complications due to diagnoses of Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD) and neither vaccine had been identified as being medically contraindicated for the Resident.Resident #4 was offered the annual Influenza vaccination when he/she had previously consented and received the Influenza vaccine in 2024. Findings include: Review of the facility's policy titled Pneumococcal Vaccine (Series), dated 11/17/25 included but was not limited to the following: -It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician- approved standing orders. -The resident's medical record shall include documentation that indicates at a minimum, the following: >The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. >The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Review of the facility's policy titled Influenza Vaccine, dated 11/17/25 included but was not limited to the following: -It is our policy to offer our residents, staff members, and volunteer workers annual immunization against influenza. -Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated or the individual has already been immunized during this time period. -Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area. -The resident's medical record will include documentation that the resident and/or the resident's representative was provided with education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindications or refusal. Review of the CDC guidance titled Pneumococcal Vaccine Timing for Adults (Pneumococcal Vaccine Timing for Adults), dated March 2025, indicated but was not limited to: -Adults ≥ [AGE] years old who have received PCV13 (Prevnar 13: vaccine used to protect against 13 types of pneumococcal bacteria that commonly cause serious infections) only at any age, PCV 20 or PCV21 would be recommended Review of CDC guidance titled Flu and People 65 Years and Older (Flu and People 65 Years and Older | Influenza (Flu) | CDC ), dated September 2024, indicated: -Flu vaccination is especially important for people 65 years and older because they are at higher risk of developing serious flu complications. -The best way to protect against flu and its potentially serious complications is with an annual flu vaccine. 1.Resident #65 was admitted to the facility in May 2025 with diagnoses including Chronic Respiratory Failure and COPD and was over the age of 65. Review of the Minimum Data Set (MDS) Assessment, dated 2/20/26 indicated Resident #65: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of four out of a possible 15 points., -was not up to date with the current influenza vaccine and the influenza vaccine was not offered. -was not up to date with the pneumococcal vaccine and the pneumococcal vaccine was not offered. Review of Resident #65's Immunization Report indicated the following: -Pneumococcal vaccine (Prevnar-13) was received 6/6/19. -Influenza vaccine was received 11/23/22. Review of Resident #65's medical record failed to indicate that the most up to date Pneumococcal and Influenza vaccinations had been offered, declined or were contraindicated. During an interview on 4/21/26 at 12:09 P.M., Infection Preventionist (IP) said she was unable to find evidence that Resident #65 had been offered, received, or declined the most recent Influenza and Pneumococcal immunizations. The IP further said that based on the Resident's current immunization record, he/she was due for the PCV20 vaccine and the annual Influenza vaccine. 2. Resident #4 was admitted to the facility in May 2023 with diagnoses including dementia, and was over the age of 65. Review of the MDS assessment dated [DATE], indicated Resident #4: -was severely cognitively impaired as evidenced by a BIMS score of four out of a possible 15 points. -had not been offered the influenza vaccine and was not up to date. Review of Resident #4's Immunization Report indicated the Influenza vaccine was last received on 10/29/24. Review of the Resident's clinical record indicated: -no documented evidence that the annual Influenza vaccine had been offered, administered or declined since 10/29/24. -Resident #4's Representative had consented for the Resident to receive the annual Influenza vaccine on 10/16/24. During an interview on 4/22/26 at 4:16 P.M., the IP said she was unable to find evidence that the annual influenza vaccine had been offered, administered or declined for Resident #4.

Based on observations, interviews, and record review, the facility failed to implement the facility's Abuse Prohibition policy and conduct an investigation for one Resident (#55), out of a total sample of 19 residents, who was observed to have an injury of unknown source.Specifically, for Resident #55, the facility failed to implement their Abuse policy related to notification, reporting, protection, and investigating a suspicious injury of swelling and bruising to the Resident's right face and right eye that the cause was not directly observed, when staff identified the injury on 4/6/26 and did not initiate an investigation until 4/17/26, delaying identification whether abuse to the Resident was occurring or has occurred, and placing him/her at risk of further abuse and injury. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation, dated 11/17/25, indicated:-Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.-Residents may be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals.-The abuse coordinator in the facility is the Director of Nursing (DON), Administrator, or facility appointed designee.-Report allegations or suspected abuse, neglect or exploitation immediately to:>Administrator>Other Officials in accordance with State Law>State Survey and Certification agency through established procedures-Identification of Abuse, Neglect, and Exploitation - the facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to, the following possible indicators: physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on the resident's body, physical injury of a resident, of unknown source .-Investigation of Alleged Abuse, Neglect and Exploitation - when suspicion of abuse, neglect or exploitation .an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.-Resident protection after alleged abuse, neglect and exploitation - the facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation.-Response and reporting of abuse, neglect and/or exploitation - anyone in the facility can report suspected abuse .When abuse, neglect or exploitation is suspected, the Licensed Nurse should:>respond to the needs of the resident and protect them from further incident (document)>Notify the Director of Nursing (DON) and Administrator (document)>Initiate the investigation immediately>Notify the attending physician, resident's family/legal representative and Medical Director>Obtain witness statements, following appropriate policies.>Contact the State Agency and the local Ombudsman office to report the alleged abuse.>If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency.>Monitor and document the resident's condition, including the response to medical treatment or nursing interventions>Document actions taken in steps above the medical record. -In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made to the Administrator of the facility and to other official (including the State Survey Agency .)-Have evidence that all alleged violations are thoroughly investigated. Resident #55 was admitted to the facility in November 2025 with diagnoses including Dementia with behaviors, restlessness and agitation, Transient Ischemic Attacks (TIA) and Cerebrovascular Accident (Stroke) and repeated falls. On 4/15/26 at 8:34 A.M., the surveyor observed Resident #55 seated in geriatric chair in one of the unit dining rooms. Resident #55 was observed with his/her eyes closed and multiple black and brown discolored areas around the right eye and the right side of the face. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #55:-has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of zero out of a possible 15 points.-physical, verbal and other behaviors during the assessment reference period.-wandering behaviors during the assessment reference period. Review of Resident #55's Comprehensive Care plans indicated:-Increased Risk of Skin Alterations in skin integrity related to impaired cognition initiated 11/19/25, indicated any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the Provider will be called as needed.-Activities of Daily Living (ADL) deficit related to dementia, initiated 11/19/25, indicated the Resident required no assistance by staff with transfers on the unit. -Potential for the Resident to be physically aggressive related to dementia, initiated 12/3/25.-Resident demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming r/t (related to) the diagnosis of Dementia and problems understanding the immediate environment. Symptoms are manifested by: Pacing, roaming or wandering in and out of peers' rooms, becoming agitated, oppositional and combative when re-directed, initiated 2/24/26. Review of the Change of Condition Note, dated 4/6/26 at 2:37 P.M., completed by Nurse #2, indicated Resident #55 was observed to have slight swelling on his/her right forehead and bluish discoloration on the right forehead in the morning. Nurse #2's Note further indicated the Resident's whole body skin check was completed, and no skin issues were noted and the Provider and Health Care Proxy (HCP - person chosen to make medical decisions when an individual is unable to do so for themselves) was notified and neurological checks were initiated. Review of Resident #55's Neurological Evaluation Flow Sheet dated 4/6/26, indicated neurological checks were initiated at 8:00 A.M. Review of the Provider Progress Note dated 4/6/26 at 4:23 P.M., indicated the following relative to Resident #55:-was evaluated by the Nurse Practitioner (NP) after nursing reported concerns for bruising noted on his/her face and crying out:>No reported falls. >has dementia, has poor safety awareness and ambulates independently. >The Resident was seen lying in bed, moaning and had significant ecchymosis (excessive bruising) to his/her right forehead.>The Resident was moving his/her extremities, and no pain was noted via palpation (touching) the Resident's extremities through his/her clothing.>The NP indicated that she suspected an unwitnessed fall given head injury and poor safety awareness. On 4/17/26 at 3:20 P.M., the surveyor requested from the DON the investigation documentation related to Resident #55's swelling and facial bruising identified on 4/6/26. On 4/17/26 at 3:24 P.M., the surveyor left a phone message for Nurse #2, who completed the Change in Condition Form relative to Resident #55's facial swelling and bruising identified on 4/6/26, requesting a return call. During an interview on 4/17/26 at 4:07 P.M., the Administrator said there was no investigation completed for Resident #55's right sided facial swelling and bruising and that the facility was starting an investigation at that time. The Administrator said the swelling and bruises on the right side of the Resident's face were of an unknown origin and an initial report was submitted to the Department of Public Health (DPH) on 4/17/26. During an interview on 4/17/26 at 4:16 P.M., the Infection Preventionist (IP) said she was made aware of Resident #55's facial bruising on 4/6/26, and they were not sure if the Resident had bumped into something or had fallen and was able to get up on his/her own. The IP said Resident #55 was previously independent with ambulation and would ambulate all over the unit. The IP said an investigation into the cause of the Resident's right facial swelling and bruising should have been completed and was not. The IP further said that the Resident's facial swelling and bruises should also have been reported to DPH because facial swelling and bruising could be an indicator that abuse could have occurred. During a follow-up interview on 4/21/26 at 1:41 P.M., the DON said she spoke with numerous staff who worked on 4/5/26 and none of the staff interviewed indicated Resident #55 had facial bruising and swelling on that date. The DON said she was able to communicate with Nurse #2, who said that when she observed the Resident at 8:00 A.M. on 4/6/26, she observed the Resident had swelling to the right side of his/her face and neuro checks were initiated. The DON said Nurse #2 further indicated that facial bruising was noticed around the same area as the swelling at around noon time on 4/6/26 and Nurse #2 completed a Change of Condition assessment and notified the Provider. The DON said when the facility staff observed Resident #55 with swelling and facial bruising, they should have immediately notified her and the Administrator because the etiology (origin) of the Resident's injuries were unknown. The DON said the Resident's right sided facial swelling and bruising of unknown etiology should also have been reported within two hours to DPH. The DON said that she was not made aware of the Resident's facial bruising and swelling on 4/6/26 and an investigation was not completed and should have been. Please refer to F609.

Based on observations, interviews and record review, the facility failed to report an injury of unknown origin within the two (2) hour requirement for one Resident (#55), out of a total sample of 19 residents. Specifically, for Resident #55, the facility failed to report the injury of unknown origin within two hours as required to the Massachusetts Department of Public Health (MA DPH) when staff observed swelling and subsequent bruising to the Resident's right eye and face on 4/6/26, and staff were unable to identify the source of the facial injury. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation, dated 11/17/25, indicated the following:-Report allegations or suspected abuse, neglect or exploitation immediately to:>Administrator>Other Officials in accordance with State Law>State Survey and Certification agency through established procedures-In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made to the Administrator of the facility and to other official (including the State Survey Agency . Resident #55 was admitted to the facility in November 2025 with diagnoses including Dementia with behaviors, restlessness and agitation, Transient Ischemic Attacks (TIA), Cerebrovascular Accident (Stroke) and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #55 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of zero out of a possible 15 points. On 4/15/26 at 8:34 A.M., the surveyor observed Resident #55 seated in a geriatric chair in the unit dining room with his/her eyes closed and multiple areas of bruising around the right eye and the right side of the face. Review of Resident #55's clinical record included the following:-Change of Condition Note dated 4/6/26 at 14:37 (2:37 P.M.) documented by Nurse #2, that indicated Resident #55 had slight swelling on his/her right forehead and bluish discoloration on the right forehead in the morning. Nurse #2 also documented that neurological checks were initiated. -Neurological Evaluation Flow Sheet dated 4/6/26, indicated neurological checks were initiated at 8:00 A.M. Review of the Healthcare Facility Reporting System (HCFRS) failed to indicate any evidence that MA DPH was notified on 4/6/26 of Resident #55's right sided facial bruising and swelling when the facility could not verify the cause of the facial injury. During an interview on 4/17/26 at 4:07 P.M., the Administrator said the swelling and bruises on Resident #55's right side of the face which were first identified on 4/6/26 were of an unknown origin and an initial report was submitted to the MA DPH via HCFRS on 4/17/26 (11 days later).During an interview on 4/17/26 at 4:16 P.M., the Infection Preventionist (IP) said she was made aware of Resident #55's facial bruising on 4/6/26, and they were not sure if the Resident had bumped into something or had fallen and was able to get up on his/her own. The IP said an investigation into the cause of the Resident's right facial swelling and bruising should have been completed and was not. The IP further said that the Resident's facial swelling and bruises should also have been reported to DPH because facial swelling and bruising could be an indicator that abuse could have occurred. During an interview on 4/21/26 at 1:41 P.M., the Director of Nursing (DON) said when the facility staff observed Resident #55 with swelling and facial bruising, they should have immediately notified her and the Administrator because the etiology (origin) of the Resident's injuries were unknown. The DON said the Resident's right sided facial swelling and bruising of unknown etiology should also have been reported within two hours to MA DPH and this did not occur. Please refer to F610.

Based on observations, interviews, and record review, the facility failed to ensure a thorough investigation was completed when an injury of unknown source was observed for one Resident (#55), out of a total sample of 19 residents.Specifically, for Resident #55, the facility failed to investigate the cause of swelling and subsequent bruising to the Resident's right face and around the right eye observed on 4/6/26, when staff were unable to identify an event that caused the facial injury, and failed to investigate the facial injury until 4/17/26 (11 days later). Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation, dated 11/17/25, indicated the following:-The abuse coordinator in the facility is the Director of Nursing (DON), Administrator, or facility appointed designee.-Report allegations or suspected abuse, neglect or exploitation immediately to:>Administrator>Other Officials in accordance with State Law>State Survey and Certification agency through established procedures-Identification of Abuse, Neglect, and Exploitation- the facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to, the following possible indicators: physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on the resident's body, physical injury of a resident, of unknown source .-Investigation of Alleged Abuse, Neglect and Exploitation- when suspicion of abuse, neglect or exploitation .an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.-Resident protection after alleged abuse, neglect and exploitation- the facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation.-Response and reporting of abuse, neglect and/or exploitation- anyone in the facility can report suspected abuse .When abuse, neglect or exploitation is suspected, the Licensed Nurse should:>respond to the needs of the resident and protect them from further incident (document)>Notify the Director of Nursing (DON) and Administrator (document)>Initiate the investigation immediately>Notify the attending physician, resident's family/legal representative and Medical Director>Obtain witness statements, following appropriate policies.>Monitor and document the resident's condition, including the response to medical treatment or nursing interventions>Document actions taken in steps above the medical record. -Have evidence that all alleged violations are thoroughly investigated. Resident #55 was admitted to the facility in November 2025 with diagnoses including Dementia with behaviors, restlessness and agitation, Transient Ischemic Attacks (TIA), Cerebrovascular Accident (Stroke) and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #55 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of zero out of a possible 15 points. Review of the Change of Condition Note, dated 4/6/26 at 2:37 P.M., completed by Nurse #2, indicated the following pertaining to Resident #55:-Resident was observed to have slight swelling on his/her right forehead and bluish discoloration on the right forehead in the morning.-Nurse #2 completed a whole-body skin check on the Resident, and no skin issues were noted. -The Provider and Health Care Proxy (HCP- person chosen to make medical decisions when the individual can no longer do so for themself) was notified and neurological checks were initiated. On 4/15/26 at 8:34 A.M., the surveyor observed Resident #55 seated in a geriatric chair with his/her eyes closed and areas of black, brown discoloration were observed around the Resident's right eye and the right side of his/her face. Review of Resident #55's Neurological Evaluation Flow Sheet dated 4/6/26, indicated neurological checks were initiated at 8:00 A.M. Review of Resident #55's Provider Progress Note dated 4/6/26 at 4:23 P.M., indicated:-Nurse Practitioner (NP) evaluation after nursing reported concerns for bruising noted on the Resident's face and him/her crying out as follows: >No reported falls.>The Resident has dementia, has poor safety awareness and ambulates independently.>The Resident was seen lying in bed, moaning and had significant ecchymosis (excessive bruising) to his/her right forehead.>The NP indicated the Resident was moving his/her extremities and no pain was noted via palpation (touching) of the Resident's extremities through his/her clothing.>The NP indicated she suspected an unwitnessed fall given head injury and poor safety awareness. On 4/17/26 at 3:20 P.M., the surveyor requested the investigation related to Resident #55's swelling and facial bruising identified on 4/6/26, from the DON. During an interview on 4/17/26 at 4:07 P.M., the Administrator said there was no investigation completed for Resident #55's right sided facial swelling and bruising. The Administrator said the facility was starting an investigation now. During an interview on 4/17/26 at 4:16 P.M., the Infection Preventionist (IP) said she was made aware of Resident #55's facial bruising on 4/6/26 and an investigation into the cause of the Resident's right facial swelling and bruising should have been completed and was not.During a follow-up interview on 4/21/26 at 1:41 P.M., the DON said she was not made aware of the Resident's facial bruising and swelling on 4/6/26, and an investigation was not completed and should have been.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for Congestive Heart Failure (CHF - when the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) for one Resident (#1) out of a total sample of 19 residents. Specifically, for Resident #1, the facility failed to appropriately care plan for and implement person-centered CHF assessment and monitoring when the Resident was admitted with a diagnosis of CHF, resulting in an unidentified 19.6 lb.(pound) weight gain and the Resident requiring further pharmacological interventions.Findings include:Review of the Heart Failure Protocol, created 11/17/25, indicated:-This protocol provides evidence-based clinical guidelines to help clinical staff and practitioners develop and implement a patient-centered treatment plan for the patient with a diagnosis of heart failure.- Organize and Develop a Patient-Centered Plan of Care>Review, organize and provide all the data when presenting patient to the IDT (interdisciplinary team) and/ or physician and other clinicians-Develop an individualized plan of care including, but not limited to:>medication management>fluid balance (e.g., measure weights routinely, document accurately and track to determine cause)>respiratory status (e.g., evaluate lung sounds, respiratory rate, presence of SOB (shortness of Breath) and/or cough, pulse oximetry, restlessness, cognitive changes)>Circulation (e.g., evaluate heart sounds, mental status, lower extremities for color, pulse, edema and capillary refill)-staff education on HF (Heart Failure) monitoring and management should be provided regularly and tailored to all levels of healthcare providers.-Consider goals of care conversations, when appropriate, as HF (Heart Failure) progresses and medical management becomes more extensive, after hospitalizations.-Additional considerations>CNAs (Certified Nursing Assistant)-Notify the nurse if you observe or identify any of the following:>increased or progressive dyspnea>activity intolerance>Anxiety>Weight change-Accurately weigh and daily weights-General recommendations>HF diagnosis should be established at SNF admission.>Potential risks for HF exacerbation should be identified and a plan of care developed.>Patients with HF should receive weight assessments, vital signs, nursing assessment of signs and symptoms, and education consistent with HF guidelines and goals of care. Bi-directional verbal and written communication among healthcare facilities and/or providers should include comprehensive clinical data. Resident #1 was admitted to the facility in March 2026 with diagnoses including Congestive Heart Failure (CHF), Pneumonia and Asthma. Review of the hospital discharge documentation indicated Resident #1 had an active diagnosis of CHF. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1:-was cognitively intact with a Brief Interview of Mental Status (BIMS) assessment score of 15 out of 15.-had no rejection of care behaviors-had a diagnosis of Heart Failure-weight of 232 lbs. (pounds) Review of Resident #1's Comprehensive Plan of Care failed to indicate:-a diagnosis of CHF.-monitoring for symptoms of CHF-monitoring of Fluid balance (measure weights routinely, document accurately and track to determine cause)-monitoring of respiratory status (evaluate lung sounds, presence of SOB and/or cough, restlessness, cognitive changes)-monitoring of circulation (evaluate heart sounds, mental status, lower extremities for color, edema and capillary refill) Review of Resident #1's CNA Care Kardex failed to indicate a diagnosis of CHF. Review of Resident #1's Physician orders for March 2026 and April 2026 indicated the following for Resident #1:-Weigh every day shift every Mon (Monday) for 4 Weeks, initiated 3/16/26-Lasix 20 mg (milligram) daily by mouth daily PRN (as needed) for edema, initiated 3/15/26 -Obtain weight only for 1 day, initiated 4/8/26 (without record of weight being obtained)-Lasix 40 mg tablet. Give 40 mg by mouth in the morning for CHF for 5 days, initiated 4/18/26 Review of the Nurse Practitioner (NP) Progress Notes for Resident #1 dated 3/23/26, indicated:-Hypertensive heart disease with heart failure and diagnosis of chronic diastolic heart failure-Has no upper respiratory infections, cough or wheezing at the time of the assessment-Plan of care was to continue Lasix 20 mg (milligrams) by mouth daily as needed (PRN) and to monitor fluid and respiratory status, BP (blood pressure), labs and weights During an interview on 4/21/26 at 8:58 A.M., Resident #1 said that he/she has not felt well with a persistent cough for a few weeks. Resident #1 said that his/her family was concerned about CHF because he/she had CHF before and it feels similar. Resident #1 said the staff weighed him/her on 4/16/26 for the first time since admission and he/she had gained 20 lbs. (19.6 lbs.) Resident #1 said he/she was concerned about the weight gain and felt like his/her condition had worsened since admission. Resident #1 said he/she had been taking Lasix at home as needed (PRN) for weight gain but had not received any Lasix since admission to the facility. Review of Weight Summary for Resident #1 indicated:3/16/26: 231.6 lbs. - obtained via mechanical lift scale4/16/26: 251.2 lbs. - mechanical lift scale (19.6 lb. weight gain in 30 days) During an interview on 4/21/26 at 9:06 A.M., Nurse #8 said Resident #1 had been coughing for about a week. Nurse #8 reviewed Resident #1's weight summary record and said Resident #1 was only weighed twice since admission, had a 20 lb. (19.6lb.) weight gain and Nurse # 8 did not know why. Nurse #8 said she was unsure if Resident #1 had CHF, then reviewed the Resident's diagnosis list and located the diagnosis of CHF. Nurse #8 said since Resident #1 has a diagnosis of CHF, they should have completed lung assessments and completed weights, but Nurse #8 was unable to provide evidence that this occurred. Nurse #8 said she did not recall listening to Resident #1's lungs prior to this past weekend. Nurse #8 said the Resident had an order for Lasix 20 mg daily PRN for edema, but he/she had not received any Lasix since admission. Nurse #8 said she could not provide any evidence that edema monitoring had occurred but said there should have been an order in place. During an interview on 4/21/26 at 9:32 A.M., Resident #1 said when he/she found out that he/she had gained 20 lbs. (19.6 lbs.), he/she did ask about getting Lasix, because he/she used Lasix at home for weight gain. Resident #1 said that the other day his/her pulse oximetry (measurement of blood oxygen saturation) was around 90 - 92% which is lower than his/her normal levels. Review of the Nurse Practitioner Progress Note for Resident #1 dated 4/21/26, indicated:-Resident was seen for follow-up on cough.-Weight of 250.4 lbs.-Chronic diastolic heart failure with 20 lb. (19.6 lb.) weight gain in one month-Continue Furosemide 40 mg daily-Change weights daily-Order BMP (Basic Metabolic Panel) and BNP (B-type natriuretic peptide [used to diagnose or evaluate heart failure]) Friday -Monitor fluid and respiratory status, labs and weights During an interview on 4/21/26 at 11:38 A.M., the Nurse Practitioner (NP) said that for any resident with CHF she expects the facility to follow the CHF protocol and obtain respiratory assessments including lung sounds and pulse oximetry. The NP said that she has been following Resident #1's respiratory status due to a recent bronchitis and performed a follow-up visit on 4/16/26 and realized the Resident had not been weighed since admission, which resulted in her asking for a weight and then discovered the 20 lb. (19.6 lbs.) weight gain had occurred and resulted in a new order for Lasix [to daily and increased dosage to 40 mg]. During an interview on 4/21/26 at 11:59 A.M., Unit Manager (UM) #1 she was unsure if the Resident had a diagnosis of CHF, then UM #1 located the diagnosis of CHF in the Electronic Medical Record (EMR) and said that since the Resident has a diagnosis of CHF, his/her weights should have been completed and respiratory assessments including lung sounds to determine fluid status should have been completed. During an interview on 4/21/26 at 4:35 P.M., the Director of Nursing (DON) said for Resident #1, the nursing staff should have met with the NP upon admission to verify the correct orders were in place for a Resident with CHF but did not. The DON said the facility did not properly assess and monitor Resident #1 for CHF, did not develop a CHF plan of care, did not provide fluid balance monitoring including weights/edema monitoring and could not provide evidence of respiratory status monitoring including lung sounds. The DON said had the facility properly assessed Resident #1 for CHF upon admission, the weight gain could have been avoided. During a follow-up interview on 4/22/26 at 10:48 A.M., the DON said the facility did not obtain the ordered weights and the NP should have been updated. The DON said had the facility followed their CHF protocol and had the NP been updated, Resident #1 could have avoided a 20 lb. (19.6 lbs.) weight gain.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the facility failed to ensure they notified the resident and the resident's representative(s) of the intent to transfer and/or intent to discharge and the reasons for the move in writing, and failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman, as required.Findings include:Review of the Facility Policy titled, Resident Transfer and Discharge Policy and Procedure, dated, 2025, indicated that before the Facility transfers or discharges a resident, the Facility shall notify the resident and the resident representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand.The Facility shall send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and maintain evidence that the notice was sent.Contents of the notice shall include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such request; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice will include the name, address and telephone number of the Office of the State Long-Term Care Ombudsman.Notice shall be made as soon as practicable before transfer or discharge when an immediate transfer or discharge is required by the resident's urgent medical needs.Resident #2 was admitted to the Facility in November 2025, diagnoses included encephalopathy (altered brain function) vascular dementia with behavioral disturbance, transient ischemic attack (TIA-temporary blockage of blood flow to the brain causing stroke like symptoms), alcohol abuse and wandering.Review of Resident #2's Nursing Progress Note, indicated that he/she was transferred from the Facility and admitted to the hospital on [DATE] and again on 12/15/25.Review of Resident #2's Medical Record indicated there was no documentation to support that the Facility provided written notification of transfer and/or discharge to the resident and/or resident representative or provided a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for Resident #2's transfers from the facility occurring on 11/26/25 and 12/15/25.During an interview on 01/20/26 at 4:05 P.M., the Director of Social Services said she could not provide any documentation to support that the Facility had provided written notification of the intent to transfer and/or discharge to the resident and/or resident representative or to the Office of the State Long-Term Care Ombudsman for Resident #2's transfers occurring on 11/26/25 and 12/15/25, as required.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was severely cognitively impaired, and was transferred to the hospital Emergency Department (ED) for an evaluation after hitting a staff member, the facility failed to ensure Resident #2 was allowed to return to the Facility once cleared by the hospital, and considered him/her discharged at the time of transfer.Findings include:Review of the Facility Assessment (document that includes an evaluation of the resident population and its needs based on evidence based, data driven models) dated last activity, 01/14/25, indicated the [NAME] Unit (Memory Care) provided specialized care to residents with all types of dementia including Alzheimer's, vascular, frontotemporal, and mixed dementia. The Facility Assessment indicated that Memory Care staff had specialized education and training in the care of individuals with dementia and that the Facility utilized a mental health agency for behavior management interventions including psychotherapy and medication management.Review of the facility policy titled, Resident Transfer and Discharge, dated 2025, indicated that residents have a right to remain in the Facility and that discharging a resident is a violation of this right unless the Facility can demonstrate that the conditions that allow for a transfer or discharge are met and that each resident is permitted to remain in the Facility unless it can demonstrate that the condition that allow for a transfer or discharge are met.Documentation in the resident's medical record shall include the basis for the transfer, the resident needs that cannot be met in the Facility, the Facility's attempt to meet the resident's needs, and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the Facility.Residents who are sent to an acute care setting such as a hospital, whether for an emergency or routine treatment/planned procedures, shall be permitted to return to the Facility.Without an assessment of the resident status and needs at the time of proposed return to the Facility, there can be no determination that the resident's needs cannot be met and/or that the safety or health of individuals would be endangered.The Facility shall document the danger that the failure to transfer or discharge would pose to other residents.Because the Facility was able to care for the resident prior to the hospitalization or therapeutic leave, documentation related to the basis for discharge shall clearly show why the Facility can no longer care for the resident.The Facility shall develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. These policies shall apply to all residents, regardless of their payment source and provide that residents who seek to return to the Facility within the bed-hold period defined in the State plan are allowed to return to their previous room, if available.The Facility shall notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing in a language and manner they understand. Resident #2 was admitted to the Facility in November 2025, diagnoses included encephalopathy (altered brain function) vascular dementia with behavioral disturbance, transient ischemic attack (TIA-temporary blockage of blood flow to the brain causing stroke like symptoms), alcohol abuse and wandering.Review of Resident #2's Minimum Data Set (MDS) assessment, dated 12/09/25, indicated he/she was severely cognitively impaired and required supervision for eating, hygiene, dressing and ambulation.Review of Resident #2's Medical Record indicated the Resident had an invoked Health Care Proxy.Review of Resident #2's Payor Information indicated his/her primary payer source was Medicaid.Review of Resident #2's Nurses Progress Note, dated 12/15/25, indicated the Resident hit Certified Nurse Aide (CNA) #1 on the head and neck. The Note indicated that it was decided by management and Nurse #2, that Resident #2 was to be sent out of the facility to the Emergency Department (ED) for evaluation and possible referral to a different facility. The Note indicated Resident #2 was transferred to the hospital.During a telephone interview on 01/21/26 at 11:05 A.M., the Hospital Case Manager (CM) said that Resident #2 had remained at the hospital since his/her transfer from the Facility on 12/15/25 (38 days). The CM said the Hospital contacted the facility on 12/16/26 and 12/18/25 regarding the Resident's ability to return to the Facility when medically ready for discharge and the Facility said they would not readmit him/her. The CM said that on 01/6/26 and on 01/7/26, the Facility was contacted again regarding Resident #2's return to the Facility but that the Facility had not responded. The CM said that Resident #2 was cooperative with care, walking the hallways with supervision, and had been medically stable for discharge for a very long time.During a telephone interview on 01/28/26 at 3:30 P.M. the Facility Business Office Manager (BOM) said Resident #2's payor source was Medicaid and that he/she had been eligible for a 20-day bed-hold when he/she was transferred to the hospital on [DATE]. The BOM said that Resident #2 had initially been placed on a Hospital Leave Bed Hold on 12/15/25, but a few days later his/her status was changed to discharged , effective 12/15/25.Review of the Facility Bed Availability Report, for the months of December 2025 and January 2026, indicated the Facility had a gender specific bed available (for Resident #2) from 12/16/25 through 01/07/26 and 01/09/26 through 1/20/26.During a telephone interview on 01/22/26 at 7:54 A.M., the Ombudsman said that a few days after Resident #2 was transferred from the Facility to the Hospital, she had received telephone calls from the Hospital Case Manager and Family Member #2 indicating the Facility would not readmit Resident #2 when he/she was ready for discharge. The Ombudsman said she contacted the Facility, and the Administrator told her that the Facility would not readmit Resident #2.Review of Resident #2's Medical Record indicated there was no documentation to support that the Facility had determined that Resident #2's needs could not have been met in the Facility or the attempts the Facility had made to meet his/her needs.During an interview on 01/20/26 at 4:15 P.M., the Director of Social Service (DSS) said she was unable to provide documentation related to which of Resident #2's needs that could not have been met in the Facility or the attempts the Facility had made to meet his/her needs. The DSS was unable to provide any documentation to support that that either Health Care Agent had been notified in writing of the reason for transfer or plan to discharge.During a telephone interview on 01/21/26 at 9:06 A.M., Family Member #1 said the Facility had called him a few days after Resident #2 was transferred to the Hospital ED and informed him that the Facility did not think they could meet Resident #2's needs. Family Member #1 said he did not know why the Facility could not meet Resident #2's needs, or what the Facility had done to try to meet his/her needs. Family Member #1 said he had not received any written notification regarding Resident #2's transfer and discharge.During a telephone interview on 01/27/26 at 4:35 P.M., Family Member #2 said she had requested that Resident #2 be re-admitted to the Facility upon discharge from the hospital. Family Member #2 said after the Hospital Case Manager informed them that Resident #2 would not be allowed to return to the Facility, she contacted the State Ombudsman's office. Family Member #2 said that Resident #2 remains stuck at the hospital and that she would like a place for Resident #2 to live. Family Member #2 said she had not been contacted by the facility or provided written notification regarding Resident #2's transfer and discharge.During an interview on 01/20/26 at 5:00 P.M., the Administrator said that the interdisciplinary team and himself had reviewed the incident that had occurred with Resident #2 on 12/15/25 and determined that they could not handle him/her and that Resident #2 could not come back to the Facility. The Administrator said that an admission Clinical Liaison (a Facility staff member that reviews potential admissions to a facility) went to the Hospital to see Resident #2 and had met with the Case Manager prior to the decision not to readmit Resident #2. The Administrator said he was unable to provide documentation of communication between the admission Clinical Liaison and the hospital, and he was unable to provide documentation indicating what needs Resident #2 had that could not be met at the Facility.

Based on observations (which included taking photographs), interviews and records reviewed, for one of two resident units, the Facility failed to ensure it provided a safe, clean, comfortable and homelike environment for their residents, when there were visible signs of unclean conditions on bathroom floors and PTAC Units (packaged terminal air conditioners, which are self-contained all-in-one heating and cooling units installed through a wall), located in resident rooms were heavily coated in dust, these conditions did not support that a homelike environment was being provided and/or maintained for residents.Findings include:Review of the Facility policy titled Environmental Services Inspection, dated 03/01/24, indicated:- Centers/Communities will closely monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.During an environmental tour of the [NAME] Unit on 09/30/25 from 7:53 A.M. to 11:09 A.M., the surveyor observed the following:room [ROOM NUMBER]: The PTAC unit top was dust laden (heavily coated), and the removable filters on the front were coated with a thick layer of dust and debris.room [ROOM NUMBER]: the PTAC unit top and front ventilation grilles were dirty and dust laden. room [ROOM NUMBER]: The PTAC unit top and front ventilation grilles were dirty and dust laden.room [ROOM NUMBER]: The PTAC unit top and front ventilation grilles were dirty and dust laden, and the walk-in shower room floor tiles were heavily stained with a black substance.room [ROOM NUMBER]: The walk-in shower room floor tiles were heavily stained with a black substance.During an interview on 09/30/25 at 8:00 A.M., after observing the surveyor in room [ROOM NUMBER], the Director of Maintenance came into the room and said the entire room was not home-like, that the PTAC unit and the black stains on the tiles in the bathroom needed to be cleaned thoroughly.On 09/30/25 between 4:45 P.M. and 5:20 P.M., the surveyor conducted a tour of the [NAME] unit with the Director of Maintenance, Administrator and representatives from the Facility's Corporate Office to review the surveyor's findings. The Director of Maintenance and the Administrator said the residents' rooms were not homelike, that the PTAC units and bathroom floors were dirty and needed to be cleaned.

Based on records reviewed and interviews, for one of four residents (Resident #3) who reported a complaint about being neglected to staff member and requested that the staff member write and submit a written complaint on his/her behalf, the Facility failed to ensure that staff implemented and followed their abuse policy, 1) related to the need to immediately report an allegation of abuse to the Administrator and/or Director of Nurses, and 2) for one of four sampled employee files (Activity Assistant #1), the Facility failed to ensure that a Massachusetts Nurse Aide Registry (NAR) background check was conducted upon hire. Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of what shift worked.Further review of the Policy indicated that potential employees would be screened for a history of abuse, neglect or misappropriation, including checking with the appropriate licensing boards and registries.1) Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/18/25, indicated that Resident #3 accused Certified Nurse Aide (CNA )#2 of neglect. The Report indicated that Resident #1 alleged that after he/she asked CNA #2 for incontinence care, he/she waited three hours for assistance.Review of a Handwritten Statement, (written by an unidentified staff member at Resident #3's request) signed and dated by Resident #3 on 08/15/25, indicated that he/she sat in an incontinence brief that was soiled with feces for three hours, despite asking CNA #2 for assistance.Resident #3 was admitted to the Facility in June 2025, diagnoses included depression and unsteadiness on feet. Review of Resident #3's admission Minimum Data Set (MDS) Assessment, dated 07/04/25, indicated Resident #3 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the Assessment indicated Resident #3 required substantial assistance from staff with Activities of Daily Living (ADLs) and mobility.During an interview on 09/16/25 at 11:23 A.M., Resident #3 said he/she did not remember all the details of the incident involving CNA #2 but said he/she asked a CNA (exact name unknown) to write a complaint describing the incident and to give it to the Administrator. Resident #3 said he/she had the CNA write the statement because his/her own handwriting was atrocious. During an interview on 09/16/25 at 4:30 P.M., the Administrator said that he was not aware of Resident #3's allegation of neglect involving CNA #2, until he found a Handwritten Statement (that was signed and dated 8/15/25) under his door on 08/18/25 (three days later). The Administrator said the incident was reported to DPH on 08/18/25 when he discovered Resident #3's Statement. The Administrator said he was unable to identify who completed the statement for Resident #3 and left it for him. The Administrator said the expectation was for staff to report any allegations of abuse immediately to their supervisor and/or administration. 2) Review of Activity Assistant #1's personnel file indicated that he was hired on 08/04/25. Further review of the File indicated that there was no documentation to support that a Massachusetts NAR background check was conducted upon hire.During an interview on 09/16/25 at 4:00 P.M., the Human Resource (HR) Representative said that he was new to his HR role, having started in May 2025. The HR Representative said he had only performed NAR checks on nurses and CNAs upon hire and did not realize they were required for all potential employees. During an interview on 09/16/25 at 4:30 P.M., the Administrator said there was no documentation to support that an NAR check was conducted on Activity Assistant #1.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that after the Director of Nurses (DON) #1 was made aware on 08/17/25 at 5:50 A.M., of allegations of abuse made by both of these residents, against Certified Nurse Aide #1, that the allegations were reported to the Department of Public Health (DPH) within two hours as required.Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will Report allegations [to the appropriate state and local authorities] involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 08/17/25 at 10:08 A.M., indicated that Resident #1 alleged that Certified Nurse Aide, (CNA) #1 was rough while providing incontinence care. The Report indicated that CNA #1 took hold of Resident #1's left leg and rolled him/her onto his/her side, which caused pain in his/her left hip. The Report further indicated that when Resident #1 asked CNA #1 to stop, CNA #1 began yelling at him/her. Review of HCFRS indicated a second abuse allegation, involving CNA #1 and Resident #2, was included in the Report submitted on 8/17/25 at 10:08 A.M., and the Department of Public Health (DPH) directed the Facility to resubmit the second incident separately as required. Review of the Report submitted by the Facility via HCFRS, dated as submitted on 08/18/25 at 6:54 P.M., indicated that on 08/17/25 at 5:45 A.M., Resident #2 alleged that Certified Nurse Aide (CNA) #1 directed profanity at him/her during care and that his/her roommate witnessed the incident. Review of a Facility Investigation Summary, dated 08/22/25, indicated the Former DON #1 (hereby referred to as DON #1) received a call at 5:50 A.M., about the incident involving CNA #1 and Resident #1.Review of a Facility Investigation Summary, dated 08/23/25, indicated DON #1 received a call at 7:30 A.M., about the incident involving CNA #1 and Resident #2.During a telephone interview on 09/17/25 at 12:20 P.M., the Director of Nurses (DON) #1 said that he did not recall the exact time he was notified of both abuse allegations.During an interview on 09/16/25 at 4:30 P.M., the Administrator said that staff are expected report any allegations of abuse to Administration immediately, and that administration, in turn, must report those allegations to DPH within two hours as required.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who had limited movement in his/her left leg and required assistance from two staff members when turning and repositioning in bed, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions related to bed mobility, when on 08/17/25, during the overnight shift, Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 without another staff member present to assist her, which caused him/her to experience pain. Findings include:Review of the Facility Policy titled: Person-Centered Care Plan, dated as revised 10/24/22, indicated the Facility must develop and implement a person-centered care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, mental and psychosocial needs that are identified in the comprehensive assessments. Further review of the Policy indicated the Care Plan must be customized to each patient's needs and describe services to be furnished. The Policy indicated that the Care Plan will be communicated to appropriate staff, patient, patient representative and family.Resident #1 was admitted to the Facility in August 2019, diagnoses included osteoarthritis, multiple sites, chronic pain syndrome, diabetes mellitus and major depressive disorder, recurrent.Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/25, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact)Further review of the Assessment indicated Resident #1's range of motion in the lower extremities was limited on both sides, and that he/she was totally dependent on staff for Activities of Daily Living (ADLs) and mobility.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as reviewed 07/10/25, indicated he/she had limited range of motion in the left leg. The Care Plan identified that Resident #1 required assistance from two staff members for bed mobility and positioning in bed. The Care Plan further indicated that Resident #1 required a mechanical lift for transfer with assistance from two staff members Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/17/25, indicated at 5:30 A.M., Resident #1 alleged that Certified Nurse Aide, (CNA) #1 was rough while providing incontinence care. The Report indicated that CNA #1 took hold of Resident #1's left leg and rolled him/her onto his/her side, which caused pain in his/her left hip. The Report further indicated that when Resident #1 asked CNA #1 to stop, CNA #1 continued with the movement. During an interview on 09/16/25 at 11:12 AM, Resident #1 said that the first time CNA #1 provided his/her care was during the incident on 08/17/25 just before 5:00 A.M. Resident #1 said that staff usually crossed his/her legs at the ankles when they rolled him/her and that he/she did not have a chance to explain that before CNA #1 suddenly grabbed his/her left leg without any warning, bent it upward, and pulled on it to roll him/her over. Resident #1 said he/she told CNA #1, You're hurting me, let go of my leg, but CNA #1 continued moving him/her until he/she was on his/her side, ignoring his/her complaint of pain. Resident #1 said that since he/she was already positioned on his/her side, he/she allowed CNA #1 to provide incontinence care and that CNA #1 was not gentle during the process. Resident #1 further said that the Facility staff did not consistently provide assistance from two staff members when assisting him/her with bed mobility.During a telephone interview on 09/18/25 at 4:23 P.M., Certified Nurse Aide (CNA) #1 said she was aware that Resident #1's Care Plan indicated that he/she required assistance from two staff members with bed mobility. CNA #1 further said that she believed she could move Resident #1 on her own if he/she helped. CNA #1 said that during rounds on 08/17/25, before 5:00 A.M. (exact time unknow), she rolled Resident #1 in bed, without assistance from another staff member because she was too busy to get help. CNA #1 said that Resident #1 stopped helping while she was rolling him/her and that she (CNA #1) would have stopped rolling him/her when asked but continued because she did not want to hurt her own back. CNA #1 said she did not mean to hurt Resident #1 during care.During an interview on 09/16/25 at 4:30 P.M., the current Director of Nurses (DON) #2 said that CNAs have access to reference the care plan interventions in the electronic medical record where they document.DON #2 said that Resident #1's Care Plan indicated that he/she required assistance from two staff members for bed mobility, and that CNA #1 should not have rolled Resident #1 without assistance from a second staff member.

Based on records reviewed and interviews, after being made aware on 8/17/25, of two separate allegations of resident abuse (the first by Resident #2 and the second a little later that same morning by Resident #1) by the same accused staff member (Certified Nurse Aide #1), the Facility failed to ensure that after being made aware of the second allegation, that they obtained and maintained evidence that a thorough investigation was completed, including but not limited to obtaining the accused staff member witness statement and/or an interview about the second allegation. Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of what shift worked.The Policy indicated that an initial investigation would be initiated within 24 hours and would be thoroughly documented within the risk management portal and would ensure that documentation of witness interviews is included.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/18/25, indicated that on 08/17/25 at 5:45 A.M., Resident #2 alleged that Certified Nurse Aide (CNA) #1 was directing profanity at him/her during care and that his/her roommate witnessed the incident. Review of the Facility Investigation file indicated there was no documentation to show that the accused CNA (#1) was interviewed about the incident involving Resident #2 on 08/17/25, and/or that a written witness statement was obtained and maintained by the Facility. During a telephone interview on 09/08/25 at 4:23 P.M., Certified Nurse Aide (CNA) #1 said she worked a double shift at the Facility through a Staffing Agency, beginning on 08/16/25 at 3:00 P.M. and ending on 08/17/25 at 5:30 A.M. CNA #1 said that said that around 5:30 A.M. on 08/17/25, Nurse #1 asked her to complete a written statement regarding an allegation of abuse that had been made by a resident she had on her assignment, and she was directed to leave the Facility. CNA #1 said that later that morning the Agency informed her of a second abuse allegation involving another resident on her assignment. CNA #1 said that although a Police Sergeant contacted her about the second allegation, no one from the Facility reached out for a statement regarding the second allegation.During an interview on 09/16/25 at 08:20 A.M., Nurse #1 said an allegation of abuse involving Resident #1 and CNA #1 was reported to her around 5:30 A.M. on 08/17/25. Nurse #1 said she instructed CNA #1 to complete a witness statement and to leave the Facility, pending investigation. Nurse #1 said that a second allegation of abuse involving CNA #1 was reported at 5:45 A.M., after she (CNA #1) had left the Facility therefore, she was unable to obtain a written statement from CNA #1, about the second allegation. During a telephone interview on 09/17/25 at 12:20 P.M., the Former Director of Nurses (hereby referred to as DON #1) said that he notified the Staffing Agency of the second allegation of abuse involving CNA #1 and asked that she no longer be assigned to the Facility. DON #1 said he did not reach out to CNA #1 for a statement as part of his investigation. During an interview on 09/16/25 at 3:50 P.M., the Current Director of Nurses (DON #2) said there was no documented evidence that a statement was obtained from the accused CNA (CNA #1) regarding the verbal abuse allegation, or that she was interviewed, as required.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2) who were both alert and oriented and dependent on staff for care, the Facility failed to ensure they were both treated in a dignified and respectful manner, when both residents reported that during the overnight shift on 08/17/25, that Certified Nurse Aide (CNA) #1 was abrupt, rude, did not respect their wishes and treated them in an undignified and disrespectful manner. Findings include:Review of the Facility Policy titled Resident Rights, dated as revised 11/28/16, indicated the facility must treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The Policy indicated the resident has the right to be treated with respect and dignity.1) Resident #2 was admitted to the Facility in August 2025, diagnoses included acute bronchitis, moderate dementia with mood disturbance, and osteoarthritis, multiple sites.Review of Resident #2's Medical Record indicated he/she was responsible for making his/her own medical decisions.Review of Resident #2's Activities of Daily Living (ADL) Baseline Care Plan, dated 08/15/25, indicated he/she was dependent on staff for bathing, bed mobility and transfers due to weakness. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/18/25, indicated that on 08/17/25 at 5:45 A.M., Resident #2 alleged that Certified Nurse Aide (CNA) #1 was directing profanity at him/her during care and that his/her roommate witnessed the incident. Review of the Facility's Investigation Summary, dated 08/23/25, indicated that CNA #1 entered Resident #2's room, whipped off the sheets and started providing care without explaining what she was doing. The Summary indicated that Resident #2 alleged that CNA #1 was rude and rough during care. The Summary further indicated Resident #4, the roommate of Resident #2, said that he/she heard CNA #1 use profanity when providing care to Resident #2.Resident #4 was admitted to the Facility in July 2025. Resident #4's most recent Minimum Data Set (MDS) Assessment, dated 08/11/25, indicated Resident #4 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a telephone interview on 09/16/25 at 11:12 AM, Resident #2 said that during his/her short term stay at the Facility in August of 2025, CNA #1 provided him/her care on two occasions and was rude and abrupt both times. Resident #2 said that early one morning (unable to recall exact date/time), when it was still dark outside, CNA #1 entered his/her room and without explaining what she was going to do, she abruptly pulled back the bed sheet and started washing the front of his/her body. Resident #2 said that when he/she did not move fast enough, CNA #1 got frustrated and directed profanity at him/her, saying What the fuck, I don't have time for this. and Move your fucking ass, I don't have all day. Resident #2 said that CNA #1 acted extremely unprofessional and that her attitude and demeaning language made him/her feel upset and very agitated. Resident #2 further said that his/her roommate overheard the entire exchange and that they both reported the incident to Nurse #1 the morning of the incident. During an interview on 09/16/25 at 11:00 A.M., Resident #4 said that he/she heard CNA #1 speaking disrespectfully and directing profanity towards Resident #2. Resident #4 said that he/she was in bed, and that CNA #1 and Resident #2 were on the other side of the privacy curtain. Although Resident #4 could not recall the exact date, he/she said the incident occurred very early one morning in August 2025, and that he/she reported the incident to Nurse #1 that same morning. Resident #4 further said that CNA #1 entered the room with a chip on her shoulder and while assisting Resident #2 with his/her care she used harsh language, telling Resident #2 move your fucking ass, I haven't got all day.During a telephone interview on 09/18/25 at 4:23 P.M., Certified Nurse Aide (CNA) #1 said that on 08/16/25 while she was working the evening shift, her boss at the staffing agency pressured her to stay for the overnight shift, into 08/17/25. CNA #1 said that she agreed to stay but said she told her boss that she was very tired and could only work until 5:00 A.M., that day.CNA #1 said that she made a second set of rounds on her residents at 4:00 A.M. so she could leave work by 5:00 A.M. CNA #1 said that Resident #2 was awake when she entered his/her room, and she helped him/her get washed. CNA #1 said she did not use profanity but acknowledged that she got agitated with Resident #2, and told him/her that he/she was aggravating her and that she had wanted to leave by 5:00 A.M. CNA #2 further said, I know I should not have said those things to Resident #2 and that I should have left and got the Nurse instead. During an interview on 09/16/25 at 08:20 A.M., Nurse #1 (which also included a review of her written witness statement dated 08/17/25) said that at 5:45 A.M. on 08/17/25, Resident #2 told her that CNA #1 had come into his/her room that morning to wash him/her up in bed and used profane language while providing care. Nurse #1 said that Resident #2 reported that CNA #1 told him/her You need to fucking move faster, and repeatedly used profanity. Nurse #1 said that Resident #4 was also present and corroborated Resident #2's account of the incident. 2) Resident #1 was admitted to the Facility in August 2019, diagnoses included osteoarthritis, multiple sites, chronic pain syndrome, diabetes mellitus and major depressive disorder, recurrent.Resident #1's Quarterly MDS Assessment, dated 06/19/25, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the BIMS. Further review of the Assessment indicated Resident #1's range of motion was limited in both lower extremities, and that he/she was totally dependent on staff for ADLs and mobility.Review of Resident #1's ADL Care Plan, dated as reviewed 07/10/25, indicated he/she had limited range of motion in the left leg. The Care Plan identified that Resident #1 required the assistance of two staff members for bed mobility and positioning in bed. The Care Plan further indicated that Resident #1 required a mechanical lift for transfer with assistance from two staff members.Review of the Facility's Investigation Summary, dated 08/22/25, indicated that on 08/17/25, CNA #1 entered Resident #1's room, did not explain what she was going to do, and began rolling him/her over in bed. The Summary indicated that when Resident #1 told CNA #1 to stop because he/she was in pain, CNA #1 did not stop the movement, and yelled at him/her. During an interview on 09/16/25 at 11:12 AM, Resident #1 said that the first time CNA #1 had provided his/her care was during the incident on 08/17/25 just before 5:00 A.M. Resident #1 said that staff usually crossed his/her legs at the ankles when they rolled him/her and that he/she did not have a chance to explain that before CNA #1 suddenly grabbed his/her left leg without warning, bent it upward, and pulled on it to roll him/her over. Resident #1 said he/she told CNA #1, You're hurting me, let go of my leg, but CNA #1 continued moving him/her until he/she was on his/her side, ignoring his/her complaint of pain. Resident #1 said that since he/she was already positioned on his/her side, he/she allowed CNA #1 to provide incontinence care and that CNA #1 was not gentle during the process.CNA #1 said she was aware that Resident #1's Care Plan indicated that he/she required assistance from two staff members with bed mobility. CNA #1 further said that she believed she could move Resident #1 on her own if he/she helped. CNA #1 said that during rounds on 08/17/25, before 5:00 A.M. (exact time unknow), she rolled Resident #1 in bed, without assistance from another staff member because she was too busy to get help. CNA #1 said that Resident #1 stopped helping while she was rolling him/her and that she (CNA #1) would have stopped rolling him/her when asked but continued because she did not want to hurt her own back. CNA #1 said she did not mean to hurt Resident #1 during care.Nurse #1 said that when she administered a medication to Resident #1, on 08/17/25 at 5:30 A.M., Resident #1 told her that CNA #1 hurt his/her left leg during care that morning. Nurse #1 said there were no visible injuries, and that Resident #1 complained of mild pain in the left leg. Nurse #1 said she administered acetaminophen to Resident #1 with good effect.During an interview on 09/16/25 at 4:30 P.M., the Administrator said that in response to the incidents involving Resident #1 and Resident #2, the Staffing Agency was informed that CNA #1 should no longer be assigned to their Facility. The Administrator further said that all residents deserved to be treated with dignity and respect.

Based on records reviewed and interviews, for two of four sampled employee personnel files (Certified Nurse Aide, (CNA) #2 and CNA #4), the Facility failed to ensure CNA #2 and CNA #4 received training upon orientation that included the prohibition of all forms of abuse, neglect, exploitation and misappropriation of resident property as required by Federal Regulations, and in accordance with Facility Policy.Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that abuse prohibition training and reporting obligations would be provided to all employees at orientation and a minimum of annually.Review of Certified Nurse Aide (CNA) #2's personnel file indicated that she was hired on 07/07/24. Further review of the File indicated that there was no documentation to support CNA #2 had received education on abuse during orientation, in accordance with the Facility's Abuse Prohibition Policy.Review of Certified Nurse Aide (CNA) #4's personnel file indicated that she was hired on 08/12/25. Further review of the File indicated that there was no documentation to support CNA #2 had received education on abuse during orientation, in accordance with the Facility's Abuse Prohibition PolicyDuring an interview on 09/16/25 at 4:30 P.M., the Administrator said that he had no documentation to support that CNA #2 and CNA #4 had received education on Abuse Prohibition, in accordance with the Facility's Policy.

Based on record review and interviews, for one of three sampled residents (Resident #3), who required medication to treat hypotension (low blood pressure) and had a Physician's order to hold (not administer) the medication for a systolic blood pressure (SBP-top number, represents the pressure in arteries when the heart contracts) greater than 115, the Facility failed to ensure the resident was free from significant medication errors when he/she was administered the medication outside of the prescribed parameter, placing him/her at risk for high blood pressure. Findings include: Review of the Facility policy titled, General Dose Preparation and Medication Administration, revised 01/01/22, indicated facility staff should: -comply with Facility policy, applicable law and the State Operations Manual when administering medications, -verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule, -confirm that the MAR reflects the most recent medication order, -if necessary, obtain vital signs. Resident #3 was admitted to the Facility in October 2023, diagnoses included Parkinson's Disease (a nervous system disorder that affects movements, often including tremors) and dementia. Review of Resident #3's Physicians' Order for May 2025, indicated it included orders for, but not limited to the following: Midodrine HCL (medication used to treat low blood pressure) oral tablet 5 milligrams (mg), give one tablet by mouth three times a day for hypotension (low blood pressure). Hold (do not give) for blood pressure with systolic (pressure) greater than 115 or diastolic (pressure) greater than 80, start date 08/21/24. Review of Resident #3's Medication Administration Record (MAR) for May 2025, indicated he/she was administered Midodrine HCL 5 mg by nursing, despite having (per nursing documentation) a systolic pressure reading that was greater than 115, (and therefore per MD orders it should have been held) on the following dates/times: 05/01/25 at 8:00 A.M., BP-126/75 05/10/25 at 2:00 P.M.-BP-116/74 05/11/25 at 8:00 A.M.-BP-157/67 05/11/25 at 2:00 P.M.-BP-122/70 05/12/25 at 8:00 A.M.-BP-122/52 05/14/24 at 5:00 P.M.-BP-124/70 05/17/25 at 8:00 A.M.-BP-125/67 05/17/25 at 2:00 P.M.-BP 116/75 05/17/25 at 5:00 P.M.-BP-118/70 05/18/25 at 2:00 P.M.-BP-116/70 05/31/25 at 2:00 P.M.-BP-118/64 During an interview on 06/11/25 at 3:30 P.M., Nurse #1 said she should not have administered Midodrine to Resident #3 on 05/01/25 and 5/12/25 at 8:00 A.M. when his/her systolic blood pressure was above 115. During an interview on 06/11/25 at 3:30 P.M., the Director of Nurses (DON) said it is the Nurses' responsibility to follow the Physician's orders on the medication administration record (MAR). The DON and the surveyor reviewed Resident #3's MAR for May 2025 and the DON said Resident #3 should not have received Midodrine on the eleven instances when his/her systolic blood pressure was documented above 115, by nursing.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who although they were cognitively impaired, were able to make themselves understood by staff, the Facility failed to ensure they were free from physical abuse, in the form of unwanted and inappropriate physical contact by a contracted employee (consulting Podiatrist). On 01/02/25, both residents reported that the Podiatrist had touched them in a sexually inappropriate manner and their recounting of the incidents to facility administrative staff and the police remained consistent. Both Resident #1 and Resident #2 reported being shocked after the incidents occurred. Based on the reasonable person concept, it would be more likely than not, that Resident #1 and Resident #2 would have experienced psychosocial harm, recurrent fear, anxiety or anger as a result of the sexual abuse since there is an expectation that they would not be touched inappropriately by a provider that had been entrusted to care for him/her. Findings include: Review of the Facility Policy titled Abuse Prohibition, dated revised 10/24/22, indicated the following: -Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. -Sexual abuse is nonconsensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. 1. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/02/25, indicated that Resident #2 reported to a Certified Nurse Aide (CNA) at 1:00 P.M., that when the Podiatrist had finished cutting his/her toenails, he grabbed his/her breasts. Resident #2 was admitted to the Facility in May 2023, diagnoses included dementia and anxiety disorder, and he/she resided on the Memory Care Unit. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 11/21/24, indicated that Resident #2 was severely cognitively impaired, with a score of 4 out of 15 on his/her Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #2's Podiatry Note, dated 01/02/25, indicated the Podiatrist trimmed his/her calluses. During an interview on 01/22/25 at 2:10 P.M., Certified Nurse Aide (CNA) #2 said that on 01/02/25 at approximately 10:30 A.M. she brought Resident #2 to the shower room, where the Podiatrist was seeing residents. CNA #2 said she left the Resident #2 alone with the Podiatrist, once he/she was seated. During an interview on 01/24/25 at 1:52 P.M., Certified Nurse Aide (CNA) #1, described the Podiatrist as average height and weight with salt and pepper hair (mixed dark and gray hair). CNA #1 said the Podiatrist often used the shower room when treating residents on the Memory Care Unit, and that the shower room door closed automatically. CNA #1 said that on 01/02/25 at approximately 1:00 P.M., Resident #2 was walking in the hallway with a strange expression on his/her face, and that she stopped him/her and asked, Are you ok? CNA #1 said that Resident #2 told her that the foot doctor touched his/her breasts and that he/she was surprised and shocked when he did that. CNA #1 said that Resident #2 told her I can't believe that happened! Review of Resident #2's Witness Statement, dated 01/02/25, as told to and documented by the Director of Social Services, indicated that Resident #2 said that the Podiatrist grabbed his/her breasts. The Statement indicated that Resident #2 said the incident occurred in the Podiatrist's room and that he/she described the Podiatrist as heavy, older, and with white hair. The Statement indicated that while the Podiatrist was touching Resident #2's breasts he/she asked the Podiatrist, What are you doing?, and that the Podiatrist responded, I am touching you. The Statement indicated that Resident #2 then told the Podiatrist Keep it to yourself buddy! Review of the Police Report, dated 01/02/25 and timed 3:28 P.M., indicated that when the Officer asked Resident #2 how his/her day had been, he/she began to talk about the Podiatrist without prompting. The Report indicated Resident #2 told the officer, He grabbed my breasts while he/she put his/her hands on his/her breasts to demonstrate. The Report indicated that Resident #2 told the Officer that the incident happened in the show room. The Report indicated that the Officer observed that Resident #2 was clearly upset about the incident. During an interview on 01/22/25 at 3:17 P.M., the Director of Social Services said that despite Resident #2's dementia, he/she was consistent with the details of his/her account of the incident on 01/02/25, when he/she was interviewed by several staff members and the police later that day. 2. Review of the Report submitted by the Facility via the HCFRS, dated 01/02/25, indicated that Resident #1 reported to staff, that when the Podiatrist had finished treating his/her feet, he put his hands down his/her shirt and felt his/her breasts. Resident #1 was admitted to the Facility in March 2021, diagnoses included dementia with mild behavioral disturbance, anxiety disorder and he/she resided on the Memory Care Unit. Review of Resident #1's Quarterly MDS Assessment, dated 11/08/24, indicated that Resident #1 was moderately cognitively impaired, with a score of 7 out of 15 on the BIMS. Review of Resident #1's Podiatry Note, dated 01/02/25, indicated the Podiatrist trimmed his/her calluses. During an interview on 01/22/25 at 1:52 P.M., the Director of Rehabilitation (DOR, which also included a review of her Written Witness Statement dated 01/02/25) said that during an Occupational Therapy session on 01/02/25 just before 1:30 P.M., Resident #1 told her that he/she was inappropriately touched earlier that morning. The DOR said that when she asked Resident #1 who had touched him/her, he/she responded, the man who came to cut my toenails, touched my breast area. Review of Resident #2's Witness Statement, dated 01/02/25, as told to and documented by the Director of Social Services, indicated that Resident #2 said I was feeling OK, until I got my toenails cut. The Statement indicated that Resident #1 reported that after the man (later identified as the Podiatrist) finished cutting his/her toenails, in his/her room, the Podiatrist put his hand down the top of his/her shirt and grabbed his/her breasts. The Statement indicated that Resident #1 described the Podiatrist as medium height with hair that was going gray. The Statement indicated that when Resident #1 told the Podiatrist What do you think you are doing? and stated You don't do this to me!, he answered I want to. The Statement indicated the Podiatrist left Resident #1's room after he/she told him to leave. The Statement indicated the incident occurred before lunch, and that Resident #1 couldn't recall the exact time. The Statement also indicated that Resident #1 was shocked by the Podiatrist's behavior and that he/she said, he was always nice to me before. During an interview on 01/22/25 at 11:20 A.M., Resident #1 told the Surveyor that some of the staff are not nice. When the Surveyor asked Resident #1 for an example, he/she responded, a doctor put his hand down my shirt. Resident #1 said The doctor for my toes put his hand down my shirt and grabbed my breasts. Resident #1 described the doctor as having dark hair that was going gray. Review of the Police Report, dated 01/02/25 and timed 3:28 P.M., indicated that Resident #1 told the Officer that the Podiatrist put his hands down the top of his/her shirt, moved them around, and touched his/her breasts. The Report indicated that Resident #1 had seen the Podiatrist before without incident. The Director of Social Services said that despite Resident #1's dementia, he/she generally had a good grasp on his/her circumstances, recognized staff and often remembered their names. The Director of Social Services said that Resident #1 tended to stay in his/her room and rarely socialized with other residents. The Director of Social Services said that despite the similarities between Resident #1 and Resident #2's allegations, she ruled out the possibility that they may have learned of each other's allegations, because both residents lived on opposite ends of the unit, were on different staffing assignments, did not generally socialize with each other, and did not seek each other out for conversation. During a telephone interview on 01/23/25 at 9:14 A.M., the Podiatrist said that he started covering podiatry services at the Facility last year and that he had been to the Facility a few times. The Podiatrist said he was at the Facility on 01/02/25 for approximately 4 hours, between breakfast and lunch, and that he saw close to 40 residents during that time. The Podiatrist said that he used the shower room to see residents when he provided services on the Memory Care Unit, and that he sometimes treated residents in their rooms as well. The Podiatrist said that the CNAs on the unit helped to transport residents to the shower room, but only assisted him during treatment if a resident was being resistant to care and needed reassurance. The Podiatrist said he was aware of the allegations against him and that he only provided the residents with routine foot checkups. The Podiatrist said that he did not act inappropriately. During an interview on 01/22/25 at 5:15 P.M., the Director of Nurses (DON) said it was alarming that two residents (Residents #1 and #2) that didn't interact with each other had the same allegation on the same day, involving the Podiatrist. During an interview on 01/22/25 at 5:30 P.M., the Administrator said the Company that provided the Podiatrist had been contacted, and that the Podiatrist was no longer allowed at the Facility.

Based on observation, interview, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) of changes in condition for two Residents (#65 and #85) out of a total sample of 19 residents. Specifically: 1. For Resident #65, facility staff failed to: -notify the Physician/NP timely of significant weight loss which resulted in delayed treatment and monitoring of the Resident, and continued significant weight loss. -notify the Resident's Legal Guardian of a change in treatment relative to significant weight loss prior to initiating medication treatment which required the Guardian's consent. 2. For Resident #85, facility staff failed to: -notify the Physician/NP of significant weight loss identified with weekly weights, resulting in inadequate treatment and monitoring of the Resident's nutritional status. Findings include: Review of the facility's policy titled Weights and Heights, dated 6/1/01 and revised 6/15/22, indicated the following: -Patients are weighed upon admission and re-admission, then weekly for four weeks, and monthly thereafter. -Additional weights may be obtained at the discretion of the interdisciplinary team (IDT). -The purpose was to obtain baseline weight, identify significant weight change, and to determine possible causes of significant weight change. -Refer to Weights and Heights procedure. Review of the facility's procedure titled Weights and Heights, dated 6/1/01 and revised 2/1/23, indicated but was not limited to the following: -A licensed nurse or designee will weigh the patient. -Admission and re-admission weights will be obtained within 24 hours of admission. -If the body weight is not as expected, re-weigh the patient. -Significant weight change is defined as >5% in one month >10% in six months -The licensed nurse will: >Notify the physician/APP and Dietician of significant changes. >Document notification of physician/APP and Dietician in the PCC Weight Change Progress Note. Review of the facility's Notification of Change in Condition policy, dated 11/28/16 and revised 7/1/24, indicated the following: -The purpose is to provide appropriate and timely information about changes relevant to the patient's condition. -A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: >a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). >a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1. Resident #65 was admitted to the facility in July 2022 with diagnoses including Dementia, Hypothyroidism, and Non-toxic Single Thyroid Nodule. Review of Resident #65's Advance Directive Care Plan, initiated 7/19/22 and revised 11/10/23, indicated: -The goal was for the Resident and Guardian to participate in decisions related to medical care and treatment. -The Resident was a full code and had a Legal Guardian. -Staff were to inform the Resident's Guardian of any changes in status or care needs. Review of Resident #65's Nutrition Care Plan, initiated 3/18/24 and revised 10/24/24, indicated: -The Resident was at nutritional risk related to gradual weight loss trend (3/18/24). -Weigh as ordered and alert Dietician and Physician to any significant loss or gain (3/18/24) -Monitor for changes in nutritional status and report to food and nutrition/Physician as indicated (3/18/24). -Monitor intake at all meals, offer alternate choices as needed, alert Dietician and Physician to any decline in intake (3/18/24). -The Resident's goal was to maintain stabilized weight of current body weight (CBW- 120 lbs ) +/- three lbs x 90 days (10/24/24 with a target goal date of 1/21/25). Review of Resident #65's Physician orders, dated 6/15/23 with a start date of 7/1/23 indicated: -weigh monthly. Review of Resident #65's Weights and Vitals Summary indicated the following weights: -7/1/24 -141.7 pounds (lbs) -8/1/24 - 136.4 lbs -9/3/24 -132.2 lbs -10/1/24 - 130.6 lbs (weight change of 7.8% over three months) -10/14/24 - 120 lbs -No weight was documented for November 2024 and December 2024 in the Weights and Vitals Summary -1/1/25 - 90.6 lbs Review of Resident #65's Nurse Practitioner (NP) Note, dated 8/9/24, indicated: -The Resident had experienced a 15 lb weight loss over the last year. -The Resident had unintended weight loss. -The Resident's body mass index (BMI) was still healthy at 23.4. -Consider caloric supplementation if needed. Review of Resident #65's Quarterly Nutrition Assessment, dated 9/16/24, indicated the following: -The Resident's usual body weight (UBW) was 145 lbs. and BMI was within normal limits (WNL) though low for age. -The Resident's diet was appropriate. -The Resident had a gradual weight loss over 180 days. -Continue to follow. Review of Resident #65's Minimum Data Set (MDS) Assessment, dated 9/16/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident was independent for eating. -The Resident weighed 132 lbs -Weight loss of greater than five percent in one month or greater than 10% in six months had not been identified. Review of Resident #65's clinical record indicated: -The Resident was discharged to the hospital on 10/10/24 related to fall with injury and readmitted to the facility on [DATE] with diagnosis of left hip fracture. -The Resident's re-admission weight obtained 10/14/24, was 120 lbs (15% weight loss over a 90-day period). Review of Resident #65's Physician orders dated 10/24/24, indicated: -House supplements with meals. Review of Resident #65's General Progress Note, dated 10/24/24, and written by the Certified Dementia Practitioner (CDP) indicated: -The Resident's Guardian had been contacted via email that same day with consent forms for medications . -An update was provided on the Resident's medical status. Further review of the General Progress Note did not include information relative to what medications required consent and what update was provided pertinent to the Resident's medical status. Review of Resident #65's November 2024 Medication Administration Record (MAR) indicated: -The Resident's weight was 120 lbs on 11/1/24. -Mirtazapine (Remeron: antidepressant medication that can be used to stimulate one's appetite and requires consent for administration) Tablet 7.5 milligrams (mg), one tablet at bedtime for Dementia was ordered for the Resident on 11/15/24. -Mirtazapine Tablet 7.5 milligrams (mg) was administered to the Resident: >11/15/24 through 11/18/24 >11/21/24 through 11/30/24 -Mirtazapine Tablet 7.5 mg was held on 11/19/24 and 11/20/24, due to no consent to administer the medication. Review of an email communication, dated 11/18/24 (three days after Mirtazapine medication was ordered and administered), from the CDP to Resident #65's Guardian indicated: -A consent for Mirtazapine was attached to the email. -The Resident was not eating well and had experienced a 10% weight loss over the last 180 days. -The Resident was often refusing to eat and often refusing to drink health shakes. -The Resident reports he/she is not hungry. -Consent to administer Mirtazapine was requested in attempt to stimulate the Resident's appetite so that he/she would begin to eat more. Review of Resident #65's clinical record included no evidence the Resident's Guardian was notified of the change in medication to administer Mirtazapine on 11/15/24 and the medication was discontinued on 12/3/24. Review of a Physician order, dated 11/20/24, indicated: -liquid protein daily, 30 cc (unit of measure) one time a day. Review of Resident #65's clinical record included no evidence the Resident was weighed in December 2024. Review of Resident #65's Weights and Vitals Summary indicated the Resident weighed 90.6 lbs on 1/1/25 (24.5% loss in three months: significant weight loss). Review of Resident #65's Quarterly Nutrition Consult, dated 1/13/25, indicated: -The Resident weighed 90.6 lbs and the Resident's BMI was 15.5 (underweight), low. -Current weight shows significant loss, 24.5% x 90 days. -Add nourishment BID (two times daily[the type of nourishment or the amount of nourishment to be provided was not indicated]). -Order weekly weights for four weeks to monitor. -No further assessment needed. Review of Resident #65's clinical record did not include any evidence that the Physician/NP was notified of: -The Resident's significant weight loss on 10/1/24 (130.6 lbs). -The Resident's continued significant weight loss on 10/14/24 (120 lbs) and 1/1/25 (90.6 lbs). -The Dietician's recommendations to add nourishment BID and order weekly weights for four weeks on 1/13/25. On 1/15/25 at 1:10 P.M., the surveyor observed Resident #65 sitting in a wheelchair in the Unit Dining Room wearing a hospital gown that was tied loosely around his/her neck, and forearms and lower legs were exposed. The surveyor observed that the Resident was very thin, both sides of the Resident's neck were sunken in behind his/her collar bone, and the Resident's exposed lower legs and forearms were thin and bony. During an interview on 1/15/25 at 1:23 P.M., CNA #1 said that staff weighed residents monthly, weekly, or daily, and that the Nurse alerted the CNAs relative to when to obtain weights. CNA #1 also said that the Nurses entered the residents' weights into the computer. During an interview on 1/15/25 at 2:04 P.M., the NP said she started providing routine coverage at the facility in October 2024 and saw Resident #65 for the first time on 10/16/24, after the Resident returned from the hospital on 10/13/24. The NP said she did not have access to any of the residents' electronic health records for about one month after she began providing routine coverage at the facility and was dependent on staff reports and a written communication log for any changes in residents' conditions during that time. The NP said she had not been alerted that Resident #65 had experienced weight loss and the facility staff did not notify her of Resident #65 having had severe weight loss. The NP said if the facility identified significant weight changes for a resident, the staff would notify her so that she could evaluate the weight loss and implement appropriate treatment interventions. The NP said if the facility had notified her of the Resident's severe weight loss, she would have ordered a chest x-ray and blood work to evaluate for malignancy. The NP said she was not notified that Resident #65's weight was 90.6 lbs on 1/1/25. The NP also said she had not yet been notified of the Dietician's recommendations from 1/13/25 to implement nourishment BID and to order weekly weights. The NP said she wished the facility had notified her of the Resident's weight loss a couple of months ago. During an interview on 1/15/25 at 3:37 P.M., the Dietician said she worked part time at the facility and she did have opportunities where she observed residents eating, but that she was only in the facility approximately one to two times per week, so she depended on staff reports and documentation for monitoring residents for nutrition. The Dietician said the facility held a Risk Meeting weekly and that Resident #65 was discussed weekly at that meeting. The Dietician also said Resident #65 was on her radar for weight loss. The Dietician said that the facility identified Resident #65 as having had a significant weight loss on 10/1/24 and the Resident's weight loss was discussed at the Risk Meeting on 10/3/24. The Dietician said that she assessed Resident #65 on 10/18/24, following the Resident's return to the facility from the hospital on 10/13/24. The Dietician said that the re-assessment she completed on 10/18/24 was due to the Resident having had a change in condition relative to a hip fracture. The Dietician said when she re-assessed the Resident on 10/18/24, she recommended house supplements. The Dietician said when she recommends house supplements for residents, either a Nurse or she will enter the order into the computer for the Physician to review within one day of the recommendation. The Dietician further said that she did not enter the order into the computer until 10/24/24 for Resident #65 to be provided with house supplements and that she was unsure why obtaining the order for the house supplements was delayed. During an interview on 1/15/25 at 4:04 P.M., with Unit Manager (UM) #1 and UM #2, UM #1 said that Resident #65 was not eating well and was losing weight when he/she returned from the hospital. UM #2 said that the Resident's Guardian had been contacted regarding initiating Remeron as an appetite stimulant, and the Guardian did not consent to Remeron being administered. UM #1 said that the facility held weekly Risk Meetings where residents with weight loss were discussed. UM #1 said that the Dietician was not always present at the meetings and would send the Risk Team an email with her recommendations for residents with weight loss if she could not be at the meeting. UM #1 said that the Dietician sent an update to the Risk Team for the meeting that was scheduled for 1/9/25 and the Dietician's recommendations included adding nourishment BID and weekly weight monitoring for Resident #65. UM #1 further said that the meeting scheduled for 1/9/25 did not occur and the recommendations made by the Dietician for Resident #65 had not yet been implemented. UM #1 said that the Risk Meeting did not have to occur in order for recommendations to be implemented. During an interview on 1/15/25 5:00 P.M., the Physician said that he had no recall of having been notified of Resident #65's significant weight loss. During an interview on 1/17/25 at 8:05 A.M., Resident #65's Guardian said the facility contacted her via email regarding the Resident's weight loss and requested consent to administer Remeron to the Resident to stimulate his/her appetite. The Guardian said that she read the email on 11/20/24 and spoke with facility staff on 11/20/24 and that staff reported wanting to initiate the use of Remeron in order to try and stimulate the Resident's appetite. The Guardian said that no other interventions had been discussed with her other than use of Remeron on 11/20/24. The Guardian said that she did not provide consent for the Remeron to be administered and she did not understand why the facility staff were recommending Remeron when other non-pharmacological interventions had not been implemented. During a follow-up interview on 1/17/25 at 10:15 A.M., the NP said she ordered 30 cc of liquid protein for Resident #65 on 11/20/24. The NP said she ordered the liquid protein specifically for bone healing due to the Resident having had a hip fracture. The NP said that the liquid protein could have some nutrition supplementation benefit, but she did not order it specific for the Resident's nutrition because she did not know the Resident had significant weight loss. 51466 2. Resident # 85 was admitted to the facility in October 2024, with diagnoses including Alzheimer's Disease, Malignant Neoplasm of Unspecified site of right breast, Major Depressive Disorder, Urinary Tract Infection, Abnormalities of gait and mobility, Generalized muscle weakness. Review of the Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated Resident #85: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -required setup assistance from staff for eating and required moderate assistance from staff for Activities of daily living (ADL) areas (dressing, bathing, positioning, transfers, ambulation). -had a weight of 150 lbs and height of 60 inches. -had no therapeutic weight approaches. -had no known weight loss or gain in the past 6 months. Review of the Medication Administration Record (MAR) for November 2024, indicated a Physician order initiated on 10/28/24, for weights to be obtained every Monday for 4 weeks. Review of Physician orders from October 2024 through January 2025, did not include any orders for ongoing weights, after the initial 4 weeks of weights were completed. Review of the Electronic Record Weights & Vital Signs Module, and MARs for October 2024 and November 2024 indicated: -No record of a weight for the 4th week after admission (11/24/24 through 11/30/24). Review of the Electronic Record Weights & Vitals indicated the following weights: -10/28/24: 150.4 lbs. -11/4/24: 139.4 lbs. (7.3% loss) -11/11/24: 139.5 lbs. -11/18/24: 144.4 lbs. -12/11/24: 140.8 lbs. -1/16/25: 130.4 lbs. (13% loss) Review of Resident #85's Nutrition Care Plan, initiated 11/14/24, indicated: -Resident was at nutritional risk related to hypercholesterolemia, Hypertension, Alzheimer's Disease, Breast Cancer, UTI, Depression, and poor intake. -Interventions included: >Weigh, as ordered. >alert Dietician and Physician of any significant weight loss or gain. During an interview on 1/15/25 at 9:11 A.M., Certified Nurses Aide (CNA) #5 said that if a resident needs to be weighed, the Nurses let the CNAs know. During an interview on 1/15/25 at 4:05 P.M., Nurse #5 said that residents are weighed upon admission, weekly for 4 weeks, then monthly or per order and the weights are documented on the MAR. Nurse #5 said if a weight loss occurs, the MD[Physician]/NP/Dietician and family are updated right away. Nurse #5 said if staff notice there is a change from the previous weight, then the Resident should be re-weighed to verify the weight is accurate. The surveyor and Nurse #5 reviewed Resident #85's medical record and Nurse #5 said there was no active Physician orders for weights and weights have not been completed since 12/12/24. During an interview on 1/16/25 at 8:14 A.M., UM #2 said Resident #85 had no active weight order and the Physician, NP, Dietician, and family had not been notified of the weight change that occurred between 10/28/24 and 11/4/24, or any other weight loss since admission, but those individuals should have been notified. UM #2 said Nurses ask the CNAs to obtain a weight, when the MAR indicates a weight is due. UM #2 said if there is a discrepancy from the previous weight, then the resident is reweighed. If the resident has a weight loss or gain, the Nurse needs to notify the MD/Family/ Dietician right away. During an interview on 1/16/25 at 12:55 PM, Dietician #1 said that every resident is weighed upon admission, weekly for four weeks then monthly. Dietician #1 said a Physician order should be in the medical record indicating how often a weight is needed. Dietician #1 said that a Nurse should have notified her and the Physician/NP of Resident #85's significant weight loss (-7.3%) on 11/4/24, but they were not notified until 1/16/25. Dietician #1 said the last time she had seen Resident #85 was for his/her admission review on 10/30/24. On 1/16/25 at 1:45 P.M., the surveyor observed staff weighing Resident #85 for a weight of 130.4 lbs. via Hoyer lift scale (lifting device used to assist caregivers). During an interview at the time, UM #1 said that this weight further indicates significant weight loss which would be reported to the Dietician and MD/NP. During an interview on 1/17/25 at 10:49 A.M., the NP said that she was not updated about Resident #85's weight loss prior to 1/16/25, and had she been updated on 11/4/24 that a weight loss had occurred, she would have put interventions into place right away to prevent further weight loss. The NP said she expected that the facility follows their weight policy, and that weights are standard orders upon admission. During an interview on 1/17/25 at 11:37 A.M., Dietician #1 said that the facility should be following their weight policy and said that had she been notified of the weight loss on 11/4/24, she would have completed another Nutrition Consult and potentially initiated nutritional interventions at that time. During an interview on 1/17/25 at 2:16 P.M., CNA #1 said that Nurses alert the CNA's when a weight needs to be obtained, either verbally or write the weight request on the assignment sheets. CNA #1 said some residents receive daily, weekly, or monthly weights depending on what the need is. CNA #1 said that if a weight discrepancy is noticed, the CNA should reweigh the resident right away or the Nurse will tell them to reweigh. CNA #1 said if the resident loses or gains over 5 lbs, they should reweigh and then the Nurse will call the Physician. CNA #1 said staff has a sitting scale, a wheelchair scale, and a Hoyer scale, and all the scales are in good working condition. Please Refer to F657, F692, and F712.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two Residents (#65 and #85) out of a total sample of 19 total residents. Specifically, the facility failed to: 1. For Resident #65, A.-address significant weight loss and implement effective interventions when the Resident was identified to have greater than 7.5 percent (%) weight loss prior to a hospitalization . -adhere to Physician orders for monthly weight monitoring. B.-implement and monitor weekly weights as required after the Resident was hospitalized and readmitted to the facility. -implement and monitor dietary interventions timely when dietary supplements, additional nourishment, and weekly weights were recommended. -adequately monitor meal and dietary supplement intakes after significant weight loss was identified by facility staff. 2. For Resident #85, -adequately monitor the Resident's weights after admission to the facility, resulting in failure to assess the Resident's significant weight loss in a timely manner. Findings include: Review of the facility's policy titled Weights and Heights, dated 6/1/01 and revised 6/15/22, indicated the following: -Patients are weighed upon admission and re-admission, then weekly for four weeks, and monthly thereafter. -Additional weights may be obtained at the discretion of the interdisciplinary team (IDT). -Hospital weight will not serve as admission or re-admission weight. -The purpose was to obtain baseline weight, identify significant weight change, and to determine possible causes of significant weight change. -Refer to Weights and Heights Procedure. Review of the facility's Weights and Heights Procedure, dated 6/1/01 and revised 2/1/23, indicated the following: -A licensed nurse or designee will weigh the patient. -Admission and re-admission weights will be obtained within 24 hours of admission. -If the body weight is not as expected, re-weigh the patient. -The weight will be entered into the Point Click Care (PCC: electronic health record) Weights/Vitals Signs module on that shift. -The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated. -Significant weight change is defined as >5% in one month >10% in six months -The licensed nurse will: >Notify the Physician/APP and Dietician of significant changes. >Document notification of Physician/APP and Dietician in the PCC Weight Change Progress Note. Review of the facility's policy titled Food and Nutrition Goals and Objectives, dated 5/1/23, indicated: -The purpose was to provide food and nutrition services to meet the physiological and psychosocial needs of patients/residents. -Resident's nutritional status is assessed, and individualized plan of care is implemented, and outcomes are monitored and evaluated to promote optimal nutritional status. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Adult BMI (Body Mass Index: calculation used as a potential health indicator) Categories dated 3/19/24, indicated the following relative to BMI for adults [AGE] years of age and older: -BMI of less than 18.5 = underweight -BMI of 18.5 to less than 25 = healthy weight -BMI of 25 to less than 30 = overweight -BMI of 30 or greater = obesity 1A. Resident #65 was admitted to the facility in July 2022 with diagnoses including Dementia, Hypothyroidism, and Non-toxic Single Thyroid Nodule. Review of Resident #65's Dietary Activity Log indicated the Resident had been receiving large portions of food for meals and fortified oatmeal for breakfast since 3/18/24. Review of Resident #65's Physician orders, dated 6/15/23 with a start date of 7/1/23, indicated: -weigh monthly. Review of Resident #65's Weights and Vitals Summary indicated the Resident weights as follows: -7/1/24: 141.7 pounds (lbs) -8/1/24: 136.4 lbs -9/3/24: 132.2 lbs -10/1/24: 130.6 lbs (weight change of 7.8% over three months) -10/14/24: 120 lbs -No weight was documented for November 2024 and December 2024 in the Weights and Vitals Summary -1/1/25: 90.6 lbs Review of Resident #65's Nurse Practitioner (NP) Note, dated 8/9/24, indicated the Resident: -was seen for an annual exam. -experienced a 15 lb weight loss over the last year. -had unintended weight loss. -body mass index (BMI) was still healthy at 23.4. -appeared well-nourished. -had no edema. -should be considered for caloric supplementation if needed. -Nursing reported good PO (per os: by mouth) intake. Review of Resident #65's Quarterly Nutrition Assessment, dated 9/16/24, indicated: -The Resident's usual body weight (UBW) was 145 lbs. -The Resident's BMI was within normal limits (WNL) though low for age. -The Resident's diet was appropriate. -The Resident had a gradual weight loss over 180 days. -Continue to follow. Further Review of the Quarterly Nutrition assessment dated [DATE], did not indicate that the Resident's weight loss from the 7/1/24 weight was addressed. Review of Resident #65's Minimum Data Set (MDS) Assessment, dated 9/16/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident was independent for eating. -The Resident weighed 132 lbs. -Weight loss of greater than five percent in one month or greater than 10% in six months had not been identified. Review of Resident #65's Weights and Vitals Summary indicated: -the Resident weighed 130.6 lbs on 10/1/24 -decreased weight from 141.7 lbs on 7/1/24 -with significant loss of 7.8% over three months (7/1/24 - 10/1/24). Further Review of the medical record did not indicate that Resident #65 has been assessed for the 7.8% weight loss identified on 10/1/24. 1B. Review of Resident #65's clinical record indicated: -The Resident was discharged to the hospital on 10/10/24, related to a fall with injury. -The Resident was readmitted to the facility on [DATE], with a diagnosis of left hip fracture. -no evidence the Resident was re-assessed by the Dietician between 10/1/24 (when the significant weight loss was identified) and 10/10/24 (when the Resident was discharged to the hospital). -no evidence the facility had implemented any new interventions to address the Resident's significant weight loss between 10/1/24 and 10/10/24, prior to the Resident being hospitalized . -The Resident's re-admission weight obtained 10/14/24, was 120 lbs. Further Review of the clinical record did not indicate that weekly weight monitoring had been implemented as required after Resident #65 was readmitted to the facility. Review of Resident #65's Nutrition Care Plan, initiated 3/18/24 and revised 10/24/24, indicated: -The Resident was at nutritional risk related to gradual weight loss trend (3/18/24). -Weigh as ordered and alert Dietician and Physician to any significant loss or gain (3/18/24). -Monitor for changes in nutritional status and report to food and nutrition/Physician as indicated (3/18/24). -Monitor intake at all meals, offer alternate choices as needed, alert Dietician and Physician to any decline in intake (3/18/24). -Offer alternate food choices if less than 50% consumed at mealtime (3/18/24). -Provide large entree portions and fortified oatmeal with breakfast (3/18/24). -The Resident's goal was to maintain stabilized weight of current body weight (CBW: 120 lbs ) +/- three lbs x 90 days (10/24/24 with a target goal date of 1/21/25). Review of Resident #65's October 2024 Physician orders indicated: -An order, initiated on 7/21/22 and discontinued on 10/31/24, for regular diet texture. -An active order, initiated 10/31/24 with no stop date, for regular liberalized diet, regular texture, standard thin liquids consistency. -An active order, initiated 10/24/24 with no stop date, for House Supplement with meals. Review of Resident #65's Nurse Practitioner (NP) Note, dated 10/16/24, indicated: -The Resident was seen for a routine visit following hospitalization . -The Resident had Dementia and decline was expected. -Continue supportive care. Further review of the NP Note did not include any evidence the Resident had been evaluated for significant weight loss. Review of Resident #65's Activities of Daily Living Care Plan, initiated 7/19/22 and last revised 10/14/24, indicated: -May require assistance for eating due to Dementia and new hip fracture 10/10/24, which is not being surgically repaired. -Provide assist of one for eating. Review of Resident #65's clinical record indicated the Dietician did not assess the Resident after re-admission to the facility on [DATE] until 10/18/24. Review of the Resident's Nutrition Consult, dated 10/18/24, indicated: -The Consult was being completed due to the Resident having had a significant change in status due to a fall and subsequent injury. -The Resident's current weight was 120 lbs, and was significant for weight loss of 13% over 180 days. -The Resident's BMI was 20.6, within normal limits, low for age. -Will add House Supplement BID (twice daily) with lunch and dinner. -Will continue to follow with changes. Review of Resident #65's Nutrition Progress Note, dated 10/18/24, indicated: -A Nutrition Assessment was completed that same day. -The Resident's Nutrition Concern(s) Category: No concern(s) identified. Review of Resident #65's Significant Change in Status MDS, dated [DATE], indicated: -The Resident was severely cognitively impaired as evidenced by a BIMS score of one out of 15 total possible points. -The Resident had no episodes of rejection of care. -The Resident required substantial/maximal assistance (helper does more than half the effort) for eating. -The Resident weighed 120 lbs. -The Resident had experienced significant weight loss and was not on a Physician prescribed weight loss regimen. Review of Resident #65's NP Notes, dated 10/19/24 and 10/21/24, indicated the Resident was seen for acute rounding visits. Neither NP Note indicated that the Resident was evaluated for significant weight loss. Review of Resident #65's Physician orders dated 10/24/24, indicated that House Supplements were not ordered for the Resident until 10/24/24 (six days after the Dietician's recommendation on 10/18/24). Further review of the Physician's orders failed to indicate: -ordered amounts for the supplement that was to be provided. -instructions for monitoring the amount of the supplements consumed by the Resident. Review of Resident #65's NP Note, dated 10/25/24, indicated: -The Resident was seen for acute rounding relative to persistent pain. -The Resident had been progressively declining since his/her hip fracture and was expected to decline. -The Resident's Guardian was in agreement to expand guardianship to change code status. -Continue supportive care. Further review of the NP Note did not include any evidence the Resident was evaluated for significant weight loss. Review of Resident #65's NP Notes, dated 10/31/24, 11/5/24, 11/8/24, and 11/13/24 indicated: -The Resident was progressively declining since his/her hip fracture and was expected to decline. Review of the 11/13/24 NP Note indicated that the Resident's current Advanced Directive was for full code (all medical measures will be taken to maintain life) status. Further review of each NP Note included no evidence that the Resident's significant weight loss had been evaluated by the NP. Further Review of the medical record did not indicate that weekly weights for Resident #65 had been obtained since re-admission to the facility. Review of Resident #65's October 2024 Medication Administration Record (MAR) indicated the following: -No house supplements were administered to the Resident on 10/24/24 and 10/25/24 (ordered by the Physician on 10/24/24). -House supplements were administered to the Resident with meals from 10/26/24 through 10/31/24. Further Review of the October 2024 MAR did not indicate the quantity of the House Supplements consumed by the Resident. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for eating indicated: -Meal percentages consumed for 30 of 56 meals provided on the day (7:00 A.M. through 3:00 P.M.) shift to the Resident were not recorded in October 2024. -Meal percentages consumed for 17 of 27 meals provided on the evening (3:00 P.M. through 11:00 P.M.) shift to the Resident were not recorded in October 2024. Review of Resident #65's November 2024 Medication Administration Record (MAR) indicated: -The Resident's weight was 120 lbs on 11/1/24. -The house supplement was administered to the Resident with meals between 11/1/24 and 11/30/24. -The Resident refused the house supplement five times. Further review of the November 2024 MARs did not include any information relative to the amounts of the house supplements the Resident consumed. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for November 2024 for eating indicated: -Meal percentages consumed for 16 of 58 meals provided on the day shift to the Resident were not recorded in November 2024. -Meal percentages consumed for four of 26 meals provided on the evening shift to the Resident were not recorded in November 2024. Review of a Physician order dated 11/20/24, indicated: -liquid protein daily, 30 cc (unit of measure) one time a day. Review of Resident #65's clinical record included no evidence that the Resident was weighed in December 2024. Review of Resident #65's NP Note, dated 12/16/24, indicated: -The Resident had trace (minimal) edema in both lower extremities. -The Resident remained a full code status. Further review of the NP Note included no evidence the Resident's significant weight loss had been evaluated by the NP. Review of Resident #65's Weights and Vitals Summary indicated the Resident weighed 90.6 lbs on 1/1/25 (24.5% loss in three months: significant weight loss). Further review of the Resident's Weights and Vitals Summary included no evidence that the Resident was re-weighed when the weight of 90.6 lbs was obtained (which indicated a loss of 29.4 lbs since the previously obtained weight in November 2024). Review of Resident #65's December 2024 Medication Administration Record (MAR) indicated: -The house supplement was administered to the Resident with meals between 12/1/24 and 12/31/24. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for December 2024 for eating indicated: -Meal percentages consumed for 16 of 56 meals provided on the day shift to the Resident were not recorded in December 2024. -Meal percentages consumed for 10 of 29 meals provided on the evening shift to the Resident were not recorded in December 2024. Review of Resident #65's January 2025 Medication Administration Record (MAR) indicated: -The house supplement was administered to the Resident with meals between 1/1/25 and 1/15/25. Further review of Resident #65's January 2025 MAR included no information to indicate the percentage of the house supplements the Resident consumed. Review of Resident #65's Certified Nurses Aide Documentation Survey Report (flow sheet) for January 2025 for eating indicated: -Meal percentages consumed for eight of 32 meals provided on the day shift to the Resident were not recorded between 1/1/25 and 1/15/25. -Meal percentages consumed for six of 14 meals provided on the evening shift to the Resident were not recorded between 1/1/25 and 1/15/25. On 1/10/25 at 9:21 A.M., the surveyor observed Resident #65 lying in his/her bed, wearing a hospital gown. The Resident was observed to have a small amount of oatmeal on the front of his/her hospital gown and was pulling the front of the hospital gown away from his/her body. Review of Resident #65's Quarterly Nutrition Consult, dated 1/13/25, indicated: -The Resident weighed 90.6 lbs and the Resident's BMI was 15.5 (underweight), low. -The Resident ate independently, supervision as needed. -Regular liberalized diet remained appropriate for promoting adequate intake to meet the Resident's estimated needs. -Meal intakes are 75-100% most meals. -Intake observation for meals was obtained via meal intake records. -Excellent appetite. -Current weight shows significant loss: 24.5% x 90 days. -Add nourishment BID (the type of nourishment or the amount of nourishment to be provided was not indicated). -Order weekly weights for four weeks to monitor. -No further assessment needed. On 1/15/25 at 1:10 P.M., the surveyor observed Resident #65 sitting in a wheelchair in the Unit Dining Room. The Resident was wearing a hospital gown that was tied loosely around his/her neck and his/her forearms and lower legs from the calf down to his/her ankles were exposed. The surveyor observed that the Resident was very thin and both sides of the Resident's neck were sunken in behind his/her collar bone, and the Resident's exposed lower legs and forearms were thin and boney. During an interview on 1/15/25 at 1:23 P.M., CNA #1 said that house supplements were delivered to the Unit by the kitchen staff and that House supplements were not stocked on the Unit. CNA #1 said that the kitchen staff sent one House supplement for each meal on Resident #65's meal trays. CNA #1 said that Resident #65 often consumed the house shakes and that the Resident enjoyed food items that were sweet tasting. CNA #1 also said that meal percentages consumed for every meal provided were to be recorded in the computer for all residents. CNA #1 said that not all meals got recorded at times when there was too much going on the Unit and if there were staff call-outs. CNA #1 said that residents are weighed monthly, weekly, or daily, depending on what the residents need and that the Nurse alerts the CNAs to weights needing to be obtained. CNA #1 said that the Nurse was responsible to enter the residents' weights into the computer as the CNAs were not allowed to enter the weights. During an interview on 1/15/25 at 2:04 P.M., the NP said she had started providing routine coverage at the facility in October 2024 and that she had seen Resident #65 for the first time on 10/16/24, after the Resident returned from the hospital on 10/13/24. The NP said she did not have access to any of the residents' electronic health records for about one month after she began providing routine coverage at the facility and that she was dependent upon staff reports and a written communication log for any changes residents may have experienced during that time. The NP said she had not been alerted that Resident #65 had experienced weight loss. The NP said if the facility identified a significant weight change, she should have been notified in order to implement effective dietary interventions, and if necessary, testing to rule out any medical causes for the significant weight change. The NP said if she had been alerted to Resident #65 having a significant weight change, she would have ordered dietary supplementation, such as health shakes, and if weight loss continued, she would have ordered a chest x-ray and additional blood work to evaluate for malignancy. The NP said that she was not notified that the Resident experienced significant weight loss in October 2024 and that the Resident's weight was down to 90.6 lbs as of 1/1/25. The NP also said she had not yet been informed of the Dietician's recommendations to implement weekly weights and nourishment BID following the Dietician's assessment on 1/13/25. The NP said she wished the facility had notified her a couple of months ago that the Resident's weight was trending down and that the Resident had significant weight loss. During an interview on 1/15/25 at 3:37 P.M., the Dietician said she worked part time at the facility. The Dietician said that she did have opportunities where she observed residents eating, but that she was only in the facility approximately one time per week, so she depended on staff reports and documentation for monitoring residents for nutrition. The Dietician said the facility held a Risk Meeting weekly and that Resident #65 was discussed weekly at that meeting. The Dietician also said Resident #65 was on her radar for weight loss. The Dietician said the facility identified Resident #65 as having had a significant weight loss on 10/1/24 and that the Resident's weight loss was discussed at the Risk Meeting on 10/3/24. The Dietician said although the Resident had a gradual weight loss over the previous year that was identified in August 2024, and a significant weight loss identified on 10/1/24, no new interventions were implemented for the Resident following the Risk Meeting held on 10/3/24. The Dietician said that she was continuing to monitor the Resident for dietary supplementation need. The Dietician said that Resident #65's meal intake percentages were not bad and that she monitored meal intake percentages based off of the meal percentage intakes that were entered into the computer. The Dietician also said the facility was good about entering meal percentage intakes. When the surveyor asked about the meal percentage monitoring when several meals were not entered into Resident #65's record, the Dietician said she did not think meal intake percentage recording had been a problem and she would have to look into it. The Dietician said that she did not see Resident #65 between 10/1/24 and 10/10/24, when the Resident was discharged to the hospital, and that she did not re-assess the Resident until 10/18/24, following the Resident's return to the facility on [DATE]. The Dietician said that the re-assessment she completed on 10/18/24 was due to the Resident having had a change in condition relative to a hip fracture and that the change in condition assessment was not triggered due to weight loss. The Dietician said that when she re-assessed the Resident on 10/18/24, she recommended house supplements. The Dietician further said she did not enter the order into the computer until 10/24/24 for the Resident to be provided with house supplements and that she was unsure why obtaining the order for the house supplements was delayed. During an interview on 1/15/25 at 4:04 P.M., with Unit Manager (UM) #1 and UM #2, UM #1 said that Resident #65 was not eating well and was losing weight when he/she returned from the hospital. UM #2 said no interventions were implemented relative to the Resident's weight loss. UM #1 said that Resident #65's weight was down to 90.6 lbs on 1/1/25, the weight was discussed at the facility's weekly Risk Meeting and no re-weight was requested by the Dietician. UM #2 said she did not think the Resident's weight of 90.6 lbs was accurate and that she had requested CNAs re-weigh the Resident. UM #2 asked the surveyor if the re-weight was in the Resident's clinical record. UM #1 was observed to review the Resident's clinical record and said that the record included no information relative to a re-weigh after the weight that was obtained on 1/1/25. UM #1 also said the Dietician did not always attend the weekly Risk Meeting and that the Dietician would provide an email to the facility with recommendations for residents. UM #1 said that the Dietician sent an update to the Risk Team for the meeting that was scheduled for 1/9/25 and the Dietician's recommendations included adding nourishment BID and weekly weight monitoring for Resident #65. UM #1 further said that the meeting scheduled for 1/9/25 did not occur and the recommendations made by the Dietician for Resident #65 had not yet been implemented. UM #1 said that the Risk Meeting did not have to occur in order for recommendations to be implemented. UM #1 also said that Resident #65 received house supplements and the amount consumed by the Resident should be monitored in the Resident's clinical record. UM #2 said she did not know why Resident #65's re-weight from 1/1/25 was not in the Resident's record and that she was going to re-weigh the Resident. On 1/15/25 at 5:15 P.M., the surveyor observed UM #2 request that CNA #6 assist her to weigh Resident #65. CNA #6 assisted the Resident to his/her room and UM #2 transported the chair scale to the Resident's room for weighing. UM #2 said the Resident's weight was 101.2 lbs. UM #2 said that the Resident's current weight still indicated a significant weight loss over the last three months. UM #2 further said, the process is broken. Let's just say that. On 1/16/25 at 8:40 A.M., during an observation and interview, the surveyor observed Resident #65 lying in bed. There were two meal carts observed on the Unit at the time and the surveyor observed CNA #2 passing meal trays from the meal carts to residents in their rooms. CNA #2 said that she was passing meal trays to residents who ate in their rooms and that she would be assisting Resident #65 to eat. The surveyor observed UM #2 in the hallway and asked UM #2 if the surveyor could observe Resident #65's breakfast meal tray. UM #2 removed the tray from the meal cart and picked up the meal ticket which indicated special request for House supplement. The surveyor observed the Resident's breakfast tray contained a covered plate and a covered bowl that UM #2 said was fortified oatmeal. The breakfast tray did not contain a house supplement. UM #2 said that the house supplement was a health shake that was to be sent to the Unit on the Resident's meal tray from the kitchen. UM #2 said that House supplements were not stocked on the Units and it was the kitchen staffs' responsibility to send the house supplements on the meal trays. UM #2 said she needed to go to the kitchen to obtain a house supplement to give to Resident #65. On 1/16/25 at 8:47 A.M., the surveyor observed Resident #65 holding a house supplement while sitting up in bed. The Resident took two sips of the house supplement through a straw, then held the supplement in front of him/herself. During an interview on 1/16/25 at 8:50 A.M., CNA #2 said that she normally assisted Resident #65 to eat breakfast. CNA #2 said that it was hit or miss relative to the Resident accepting the house supplement. CNA #2 said that she found that the Resident more frequently did not accept the house supplement than accept the house supplement at breakfast. CNA #2 also said that Resident #65 required physical assistance from staff to eat. On 1/16/25 at 9:10 A.M., the surveyor observed Resident #65 positioned upright in bed. CNA #2 was seated next to the Resident's bed assisting the Resident to eat. The Resident was eating slowly and accepting small bites of french toast. The surveyor observed the bowl of fortified oatmeal was uncovered, and the bowl was still full. During an interview on 1/17/25 at 7:55 A.M., the Regional Nurse said Nurses are triggered to obtain residents' weights when they view the administration records in the electronic health records. The Regional Nurse said that when the Nurse records the weights into the administration record, that record of weight does not automatically transfer into the Weights and Vitals module in PCC and the Nurse would then have to also enter the weight into the Weights and Vitals module. The Regional Nurse said that he would not expect the Nurses to have to record the weight twice because the weight was already recorded in the clinical record. The Regional Nurse also said that the Weights Exception Report was generated by the weights entered into the Weights and Vitals module in PCC, so if only the Weights Exception Report was being reviewed, staff would miss identifying significant weight changes if not reviewing all of the weight information in the clinical record. The Regional Nurse said that the Nurses were responsible to determine whether a weight obtained was accurate, whether a re-weigh was required, and obtain a re-weight. During a follow-up interview on 1/17/25 at 10:15 A.M., the NP said she ordered 30 cc of liquid protein for Resident #65 on 11/20/24. The NP said she ordered the liquid protein specifically for bone healing due to the Resident having had a hip fracture. The NP said that the liquid protein could have some nutrition supplementation benefit, but that she did not order it specific for the Resident's nutrition because she did not know the Resident had significant weight loss. 51466 2. Resident #85 was admitted to the facility in October 2024, with diagnoses including Alzheimer's Disease, Malignant Neoplasm of Unspecified site of right breast, Major Depressive Disorder, and Urinary Tract Infection. Review of the Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated Resident #85: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -required setup assistance from staff for eating and required moderate assistance from staff for Activities of Daily Living (ADL) areas (dressing, bathing, positioning, transfers, ambulation). -had a weight of 150 lbs and height of 60 inches. -had no therapeutic weight approaches. -had no known weight loss or gain in the past 6 months. -was at risk for developing pressure ulcers. Review of the Electronic Record Weights & Vital Signs Module, and Medication Administration Records for October 2024, November 2024, and December 2024, indicated the following weights were obtained: -10/28/24: 150.4 lbs (three individual weight entries of 150.4 lbs were documented on this date) -11/4/24: 139.4 lbs (decrease of 7.3 % in less than 30 days) -11/11/24: 139.5 lbs. -11/18/24: 144.4 lbs. -No evidence of weight obtained on the fourth week after admission. (11/24/24 through 11/30/24) -12/11/24: 140.8 lbs. -No evidence of the Resident having been weighed between 1/1/25 and 1/15/25 (prior to the surveyor's inquiry on 1/16/25). -1/16/25: 130.4 lbs (20 lbs. weight decline since admission and 13% weight decline over three months/ 90 days). Further review of the Weights & Vitals Record indicated the Resident experienced a 7.3 % weight loss (significant) from 10/28/24 to 11/4/24. There was no evidence that a re-weigh was obtained after the weight obtained on 11/4/24, that validated the accuracy of the Resident's weight. Review of Resident #85's clinical record did not include evidence that the facility assessed the Resident to determine if interventions should be implemented to address the weight loss. Review of the Nutrition Care Plan initiated 11/18/24, for Nutritional Risk, indicated Resident #85: -was at nutritional risk related to Alzheimer's disease, breast cancer, Depression and poor intake. -Weigh as ordered, and alert Dietician and Physician of any significant weight loss or gain. -Honor food preferences within meal plan. -Monitor for changes in Nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. -Monitor intake at all meals, offer alternative choices as needed, alert Dietician and Physician to any decline in intake. During an interview on 1/15/25 at 9:11 A.M., CNA #5 said that if a resident needed to be weighed, the Nurses let the CNAs know. During an interview on 1/15/25 at 4:05 P.M., Nurse #5 said that residents are weighed upon admission, weekly for 4 weeks, then monthly or per order and the weights are documented on the MAR. Nurse #5 said if a weight loss occurs, the MD[Physician]/NP/Dietician and family are updated right away. Nurse #5 said if staff notice there is a change from the prev [TRUNCATED]

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for falls, with interventions for safety that included the assistance of one staff member with toileting, transfers and mobility, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety, when on 06/26/24, Certified Nurse Aide (CNA) #1 left Resident #1 unsupervised and unattended standing with his/her walker in the bathroom, Resident #1 fell backwards to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured left scapula (shoulder blade), and was also noted to have a right elbow skin tear. Findings include: The Facility's Policy, titled Falls Management, dated 03/15/24, indicated residents would be assessed for risk for falls and interventions would be implemented as appropriate, including staff providing strategies to minimize risk for falls. Review of the Report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 06/27/24, indicated Resident#1 fell backwards in his/her bathroom while standing with his/her walker. The Report indicated, Resident #1 was left unattended while CNA #1 went to get his/her recliner chair that was out in the hallway. The Report indicated Resident #1 sustained a fractured left scapula and right elbow skin tear and a small cut on his/her right eyebrow. Resident #1 was admitted to the Facility in December 2023, diagnoses included history of falls, abnormalities of gait and mobility, muscle weakness and dementia. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 05/24/24, indicated he/she required maximum assistance with care and required partial to moderate assistance from one staff member for ambulation. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her May MDS, indicated intervention (dated as initiated on 12/11/23) included for staff to provide extensive assistance of one for transfers and minimum to moderate assistance of one for toileting. Review of Resident #1's Care Kardex Report (utilized by Certified Nurse Aides, provides direct care staff with a brief overview of each resident's needs), indicated he/she required limited assistance of one staff member to stand and transfer with his/her walker. Review of Resident #1's Lift Transfer Evaluation, dated 06/01/24, indicated he/she was assessed by the Rehabilitation Department as requiring limited to minimal assist to stand, pivot, and transfer. Review of Resident #1's Occupational Therapy Discharge Summary, dated 06/26/24 indicated he/she was unable to stand without upper extremity support and an assistive device for 10 seconds. Review of Resident #1's Nurse Progress Note, dated 06/27/24, indicated that CNA #1 left Resident #1 standing alone with his/her walker in the bathroom doorway, then a few seconds later Nurse #1 heard a bang and found Resident #1 on the floor in his/her bathroom after he/she had fallen backwards. The Note indicated Resident #1 sustained injuries on his/her left humerus (upper arm bone), right elbow and right forehead and was transferred to the Hospital Emergency Department. Review of Resident #1's Hospital X-ray Report of his/her left shoulder, dated 06/27/24, indicated he/she had a fracture of the left scapula. Review of Resident #1's Hospital Discharge Summary, dated 07/01/24, indicated he/she was admitted to the Hospital 06/27/24, diagnosed with a left scapular fracture requiring an orthotic sling and found to have a chronic pulmonary embolism. During an interview on 08/22/24 at 3:23 P.M., Nurse #1 said on 6/26/24 at approximately 9:05 P.M., she had administered medication to Resident #1's roommate, and as she was exiting the room to return to her medication cart (located just outside the room) she saw Resident #1 and CNA #1 on their way out of the bathroom. Nurse #1 said she heard CNA #1 trying to talk Resident #1 into going into bed instead of sleeping in his/her recliner chair that was in the hallway (and needed to be brought into the room) and he/she declined. Nurse #1 said she heard CNA #1 pulling the recliner chair into the room. Nurse #1 said while she was outside the door to Resident #1's room, at her medication cart, she heard a bang, went back into Resident #1's room and found Resident #1 lying on the floor in the bathroom after falling backwards. Nurse #1 said CNA #1 had left Resident #1 standing in the bathroom doorway, unattended, to bring the recliner chair into the room. Nurse #1 said Resident #1 complained of pain and said my shoulder is broken. Nurse #1 said after assessing Resident #1 for injuries, she and CNA #1 lifted him/her up off the floor, placed him/her in the recliner, and she obtained an order to transfer Resident #1 to the Hospital Emergency Department. During an interview on 08/23/24 at 9:46 A.M., CNA #1 said she knew Resident #1 had a history of falls and that he/she should not have been left standing in the bathroom unsupervised. CNA #1 said she left Resident #1 standing with his/her walker in front of the toilet and left the bathroom to bring a linen bag and a trash bag out in the hall to clear the clutter and said she had asked Nurse #1 to watch Resident #1 and then heard him/her fall. During an interview on 08/22/24 at 2:08 P.M., CNA #2 said Resident #1 required assistance with all Activities of Daily Living (ADL's) and that she would not leave him/her unattended or alone standing in the bathroom. During an interview on 08/22/24 at 2:15 P.M., The Administrator said that when she completed the facility's investigation that there were inconsistencies with CNA #1's statement, related to the details of where she was at the time of the fall and what she was doing. The Administrator said Resident #1 was left unattended by staff standing with his/her walker, but should not have, fell in the bathroom and sustained injuries requiring a hospital stay.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure Residents were free from verbal abuse, when on 12/15/21 at approximately 5:00 P.M., in Dining Room One with multiple other residents present, two staff members witnessed Certified Nurse Aide (CNA) #1, in an angry loud voice, say shut up to Resident #2 who was talking loudly, and then moments later, in an angry loud voice, say shut up to Resident #1 who was singing loudly. When Resident #2 continued to talk loudly, CNA #1 then turned to Resident #2 and said words to the effect of, What the [OBSCENITY] is wrong with you. Finding include: Review of the Facility's Policy titled Abuse Prohibition, dated 4/09/21, indicated that the Facility prohibits the mistreatment, neglect, and abuse of residents. Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of their age, ability to comprehend or disability. Review of Resident #1's Medical Record indicated his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's most recent Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she usually has the ability to understand others, can usually make her/himself understood, and has severe cognitive impairment. Review of Resident #2's Medical Record indicated his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's most recent Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she usually has the ability to understand others and can usually make her/himself understood, and has severe cognitive impairment. During an interview on 1/11/22 at 12:20 P.M., the Maintenance Assistant said that Dining Room One (used for assisting and supervising residents with eating) is a fairly square room which measured 24 feet in length and 22 feet in width. During an interview on 1/11/22 at 12:22 P.M., CNA #3 said on 12/15/21 at approximately 5:00 P.M., CNA #1 was already in a bad mood after Resident #2 had hit CNA #1's arm when she and CNA #1 repositioned Resident #2 was in a chair in Dining Room One. CNA #3 said that minutes later, she was at the doorway of Dining Room One and heard CNA #1 say loudly in an angry tone to another resident (Resident #1), Shut up. CNA #3 said she only intermittently assisted in Dining Room One, although CNA #1 and CNA #2 were both assigned to Dining Room One. During an interview on 1/11/22 at 12:30 PM, CNA #2 said that on 12/15/21 at approximately 5:00 P.M., she witnessed three brief interactions between CNA #1 and Resident #1 and Resident #2 in Dining Room One. CNA #2 said that 14 other residents were present at the time of this incident, all of which were within hearing distance of CNA #1 who was talking to Resident #1 and Resident #2 in an abusive, loud manner, and using profanity. CNA #2 said while CNA #1 was talking to other staff members, Resident #2 was delusional (verbalizing false believes) and was yelling out, but it was not directed at anyone. CNA #2 said CNA #1 turned around, looked at Resident #2 from approximately five feet away, and said loudly in an angry tone of voice, shut up! CNA #2 said that CNA #1 then turned back towards the staff and continued talking with them. CNA #2 said Resident #2 did not respond to CNA #1's, words and continued talking loudly. CNA #2 said Resident #1 started singing and screaming words loudly with a noise level that was high for such a small room. CNA #2 said CNA #1 turned around and looked at Resident #1 from approximately ten feet away, and said loudly in an angry loud voice, saying the Resident's name and shut up! CNA #2 said Resident #1 did not respond. CNA #2 said at this time that, Resident #2, then started yelling again, and CNA #1 turned to Resident #2 and said out loud in an angry voice, words to the effect of, What the [OBSCENITY] is wrong with you! During an interview on 1/11/22 at 3:45 P.M., CNA #1 said she denied saying shut up to Resident #1 and Resident #2, or saying to Resident #2, words to the effect, What the [OBSCENITY] is wrong with you. Review of the Facility's Internal Investigation, dated 12/16/21, indicated that on 12/5/21 at approximately 5:30 P.M., several residents from the Dementia Unit were in Dining Room One for dinner. There were residents singing, talking and vocalizing. CNA #1 told the residents to shut up several times, then CNA #1 asked the residents, What the [OBSCENITY] is wrong with you. Review of CNA #2's written witness statement, dated 12/15/21, indicated the following: While on the secured Dementia Unit, CNA #1 began to raise her voice and yell at residents. CNA #1 said in a loud voice to a Resident a who was yelling, Shut up and CNA #1 persisted to tell other residents to Shut up and when one resident was yelling aggressively, CNA #1 raised her voice and said, What the [OBSCENITY] is wrong with you. When CNA #1 was approached by the staff about the way she was speaking to the Residents, CNA #1 said that she could not handle this place anymore. Review of CNA #3's written witness statement, dated 12/16/21, indicated the following: On 12/15/21 during the dinner time meal, she was working between two Dining Rooms. Prior to the verbal abuse, she (CNA #3) assisted CNA #1 in repositioning Resident #2 in his/her chair, and Resident #2 hit (with an open hand) CNA #1's arm. Minutes later in Dining Room One, another resident, Resident #1 was singing, and CNA #1 said directly to Resident #1, Shut up. During an interview on 1/11/22 at 10:20 A.M., the Director of Nurses, said the Facility investigation found CNA #1's comments towards the residents to be substantiated for verbal abuse. During interviews on 1/11/22 at 1:55 P.M. and at 2:00 P.M., with Resident #1 and Resident #2, both residents were confused and did not respond to the questions about the manner CNA #1 spoke to them, on 12/15/21 in Dining Room One. Although Resident #1 and Resident #2 were unable to provide an account of alleged verbal abuse by CNA #1, a reasonable person of intact cognitive functioning would have experienced mental anguish.

Based on record review and interview, the facility staff failed to develop a baseline care plan for one resident (#184), who was identified as at risk for falls on admission, in a total of 18 sampled residents. Findings include: Resident #184 was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the record indicated nursing documentation on 3/4/21 specified Resident #184 was identified as a fall risk. Further review of the record indicated there was no baseline care plan developed within 48 hours of admission, as required. Review of a fall investigation, dated 3/14/21, indicated the fall occurred at 10:45 A.M. and was unwitnessed. Further review of the report indicated the resident had pain with movement and was sent to the hospital by the Nurse Practitioner for further evaluation. Review of the hospital records, dated 3/14/21, indicated a right femoral neck fracture (hip fracture) with valgus deformity and mild impaction. Further review of the record indicated the resident's legal guardian was contacted to discuss treatment options. Documentation indicated the guardian decided not to pursue surgical repair of the fracture, and so, the resident was returned to the facility. During an interview on 4/1/21 at 8:10 A.M., the Director of Nurses (DON) said fall assessments were done as part of the admission nursing documentation and baseline care plans were developed within 48 hours of admission in the electronic record. She said the reference point for the baseline care plans was date initiated. The surveyor and DON reviewed Resident #184's record and there was no evidence a baseline care plan was developed within 48 hours of admission, as required. Further review of the record indicated there was no falls care plan in place from admission until a falls care plan was initiated on 3/17/21 status post [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/1/21 at 9:22 A.M., the Administrator said the facility self-identified that a baseline care plan had not been developed within 48 hours of admissions, as required. She further said they made the discovery during their post fall investigation and initiated a quality improvement plan at that time to address baseline care plans and falls (see below). On 4/1/21 the facility demonstrated past non-compliance as of 3/29/21 and presented the surveyor with a plan of correction which addressed the areas of concern as evidenced by: A. Quality Assurance Performance Improvement (QAPI) plan was initiated on 3/19/21 to reduce falls. B. Nursing staff was re-educated to establish and implement baseline care plans and immediate fall interventions for all new admissions. The education was completed on 3/20/21. C. Audits were completed for all new admissions on 3/24/21 and 3/29/21 to ensure baseline care plans were established as required. D. Continuous monitoring of the project is in place by the QAPI committee. See F689

Based on record review, observation and interview, the facility failed to develop fall prevention interventions for one resident (#184) who was identified as a fall risk on admission, from 18 sampled residents. Resident #184 sustained a fall with a [CONDITION(S)] on 3/14/21 and suffered a subsequent significant decline in functional status. Findings include: Resident #184 was admitted to the facility in March of 2021 with diagnoses including dementia and restless leg syndrome. Review of the record indicated Fall Risk Assessments (dated 3/4/21, 3/5/21 and 3/6/21) that indicated a score of 1.0 -Fall Risk Identified. Review of a nurse's note, dated 3/6/21, indicated Resident #184 wandered daily/almost daily and experienced restlessness, agitation and exit seeking behaviors. Review of a nurse's note, dated 3/8/21, indicated Resident #184 was highly confused at baseline and was ambulating in the halls and exit seeking. Review of an Admission Minimum Data Set (MDS) Assessment, dated 3/10/21, indicated the following: -Resident #184 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. -Resident #184 performed bed mobility, transfers, walking, toilet use, dressing and hygiene with supervision and set-up from staff. Review of a nurse's note, dated 3/13/21, indicated Resident #184 had left and right lower extremity weakness and indicated the resident was experiencing agitation/restlessness. Review of a nurse's note, dated 3/14/21, indicated staff responded to Resident #184 calling out from his/her room and found the resident on the floor lying on his/her back. Further review indicated the resident was too confused to recall the events of the fall, but complained of right hip pain. Review of a fall investigation, dated 3/14/21, indicated the fall occurred at 10:45 A.M. and was unwitnessed. Further review of the report indicated Resident #184 had pain with movement and was sent to the hospital by the Nurse Practitioner for further evaluation. Review of the hospital records, dated 3/14/21, indicated a right femoral neck fracture ([CONDITION(S)]) with valgus deformity and mild impaction. Further review of the record indicated the resident's legal guardian was contacted to discuss treatment options. Documentation indicated the guardian decided not to pursue surgical repair of the fracture, therefore, Resident #184 was returned to the facility. Review of a Significant Change MDS Assessment, dated 3/23/21, indicated the following: -Resident #184 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15. -Resident #184 performed bed mobility, transfers, toilet use, dressing and hygiene with extensive assist of 2 staff. The MDS further indicated walking in the room and corridors occurred only once or twice during the 7 day look back period. During an observation on 3/31/21 at 10:16 A.M., Resident #184 was observed in bed on an air mattress. The bed was in the lowest position and there were fall mats in place at bedside. During an interview on 4/1/21 at 8:10 A.M., the Director of Nurses (DON) said fall assessments were done as part of the admission nursing documentation and baseline care plans were developed within 48 hours of admission in the electronic record. She said the reference point for the baseline care plans was date initiated. The surveyor and DON reviewed Resident #184's record and there was no evidence a baseline care plan was developed within 48 hours of admission, as required. Further review of the record indicated there was no fall prevention care plan in place from admission until a falls care plan was initiated on 3/17/21 status post fall. The DON said she was not sure why there was no evidence of a baseline care plan on admission and said she would need to talk to the administrator because she was not working at the facility at that time. During an observation on 4/1/21 8:30 A.M., Resident #184 was observed in bed, with the bed in its lowest position with bedside mats in place. Nurse #2 said the resident had just moved from another unit after completing a 14 day re-admission quarantine. She further said the resident was non-ambulatory and extensive assist to dependent for most care due to a recent [CONDITION(S)] without surgical repair. During an interview on 4/1/21 at 9:22 A.M., the Administrator reviewed the fall assessments, with the surveyor, for Resident #184 and said the resident was assessed as a fall risk at admission. The Administrator further said the facility self-identified that a baseline care plan had not been developed and fall interventions were not put into place for Resident #184 prior to the fall on 3/14/21. She further said they made the discovery during their post fall investigation and initiated a quality improvement plan at that time to address baseline care plans and falls. On 4/1/21 the facility demonstrated past non-compliance as of 3/29/21 and presented the surveyor with a plan of correction which addressed the areas of concern as evidenced by: A. A Fall Risk care plan was initiated for Resident #184 on 3/17/21 due to cognitive impairment and poor safety awareness. The care plan also addressed the right [CONDITION(S)] sustained on 3/14/21 without surgical repair. B. A Quality Assurance Performance Improvement (QAPI) plan was initiated on 3/19/21 to reduce falls. C. Nursing staff was re-educated to establish and implement baseline care plans and immediate fall interventions for all new admissions. The education was completed on 3/20/21. D. Audits were completed for all new admissions on 3/24 and 3/29/21 to ensure baseline care plans and fall interventions were established as required. E. Continuous monitoring of the project is in place by the QAPI committee.

Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions to prevent a fall with a major injury for 1 Resident (#87), in a total sample of 21 residents. Resident #87 was admitted to the facility in May of 2019 with a [DIAGNOSES REDACTED]. Review of a Fall Risk Evaluation, dated 11/22/19, indicated that a score of 12 or above indicated a high risk of falls. Resident #87 scored a 27. Review of the clinical record indicated Resident #87 fell on [DATE], 12/6/19, and 12/13/19. For all three falls, the resident had a bed alarm in use, which sounded at the time of the fall. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/5/19, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 7 out of 15, required extensive assistance for transfers and toileting and used a bed alarm daily. The MDS Assessment also indicated the resident fell 2 or more times with no injury, and once with an injury. Review of a Fall Incident Report indicated the resident had a fall in his/her room on 1/4/20 at 4:00 P.M. and sustained a head injury. Preventative measures implemented prior to the fall, per this report, included: -Encourage(NAME)to stay in supervised area when awake -Bed pad alarm to bed-check function and positioning every shift. The report indicated the resident had an unwitnessed fall in his/her room and had hit his/her head. An alarm had been assigned to the resident but had not been turned on. The alarm did not sound, but the alarm battery was deemed in good working order. The resident was sent to the emergency room and required 3 staples to the occipital (back) of the head. During an interview with Unit Manager (UM) #2 on 1/31/20 at 1:30 P.M., she said the resident's fall on 1/4/20 was not witnessed. The bed alarm was present, but had not been turned on. She said the Certified Nurses' Aide (CNA) assigned was from an agency. The facility has been unable to reach her. UM #2 said there was no system to monitor the function and placement of bed alarms. During an interview with the Director of Nurses on 1/31/20 at 3:34 P.M., she said the facility didn't use alarms as fall prevention because they don't work. She said bed alarms don't work and won't prevent a fall, they are just an alert. When asked if they were alerted to this most recent fall, she reiterated the alarm was not used to prevent falls. She agreed they did not implement the alarm, however.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that he/she was free from abuse, when on 11/30/19, Resident #1, who was seated in a wheelchair, was physically restrained when Nurse #1 utilized a bed sheet, wrapped it around Resident #1's waist, brought the bed sheet behind Resident #1's wheelchair and secured it by knotting it in the back, which prevented Resident #1 from getting up, and he/she was left restrained in the wheelchair for approximately four and a half hours, so she could attend to other residents. Findings include: The Facility's Internal Investigation, dated 11/30/19, indicated Certified Nurse Aide (CNA) #1 alleged that Nurse #1 restrained Resident #1 in a wheelchair using a sheet in a seat belt fashion. The Investigation indicated Nurse #1 admitted that she did restrain Resident #1 using a sheet loosely wrapped around his/her waist and tied behind the wheelchair because Resident #1 was agitated. The Health Care Facility Reporting System (HCFRS) Report, dated 11/30/19, indicated that during the 11:00 P.M. to 7:00 [NAME]M. shift, Certified Nurse Aide (CNA) #1 witnessed that Nurse #1 had physically restrained Resident #1 in a wheelchair. CNA #1 reported the use of the restraint to the Administrator at 9:00 [NAME]M. on 11/30/19. CNA #1's written witness statement, undated, indicated that on 11/30/19, at approximately 3:00 [NAME]M. during incontinent rounds, she (CNA #1) observed that there was a waist restraint on Resident #1. The Statement indicated CNA #1 looked to Nurse #1 to question the restraint and that Nurse #1 said words to the effect, I have to do what I have to do. The Surveyor interviewed CNA #1 at 10:05 [NAME]M. on 12/13/19. CNA #1 said on 11/30/19 at approximately 3:00 [NAME]M., Resident #1 was restrained with a bed sheet wrapped around his/her waist and secured to the back of his/her wheelchair with a double knot, that Resident #1 could not get out of the wheelchair, and that he/she was agitated while in the restraint. The Surveyor interviewed CNA #2 at 10:46 [NAME]M. on 12/13/19. CNA #2 said at approximately 6:00 [NAME]M. on 11/30/19, he observed Resident #1 sitting in a wheelchair in the dining room, he/she had a sheet across his/her lap and he could see that the sheet was knotted on the back of the wheelchair. The Facility's Policy, titled, Abuse Prohibition, dated 7/1/19, indicated that: - The Facility prohibits abuse, mistreatment, neglect, physical and chemical restraint not required to treat the patient's medical symptoms. - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish, freedom from corporal punishment. The Facility's Policy, titled Use of Restraints, dated 11/1/19, indicated that: -Residents have the right to be free from any physical or chemical restraint imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. -Physical restraint is any manual method, physical or mechanical device, equipment or material that meets all of the following, is attached or adjacent to the resident's body, cannot be removed easily by then resident and restricts the resident's freedom of movement or normal access to his/her body. Review of Resident #1's plan of care related to his/her [DIAGNOSES REDACTED]. There was no documenation in Resident #1's plan of care to support that a restraint was identified as an intervention. Review of Resident #1's physician's orders [REDACTED]. Nurse #1's witness statement obtained by the Administrator via a telephone interview, indicated that Nurse #1 said she restrained Resident #1 because there was only 1.5 CNAs on the 11:00 [NAME]M. to 7:00 [NAME]M. shift on the unit that night, that Resident #1 was restless, another resident had fallen on the unit and it was in her best nursing judgement to restrain Resident #1. Although Resident #1 was unable to recall the incident to the Surveyor due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would have mental anguish from being physically restrained involuntarily. The Surveyor interviewed Nurse #1 at 6:00 P.M. on 12/16/19. Nurse #1 said she had a background in behavioral health (at a different facility) in which restraints were used as needed. Nurse #1 said she placed Resident #1 in a restraint while he/she was in a wheelchair, with a sheet wrapped around his/her waist, secured behind the wheelchair for approximately 4.5 hours because he/she had escalating psychiatric behaviors, physical aggression and hallucinations and that she could not continually keep an eye on him/her The Surveyor interviewed the Administrator at 8:28 [NAME]M. on 12/13/19. The Administrator said that the investigative findings were that Nurse #1 restrained Resident #1 with a sheet tied to the back of his/her wheelchair without a physician's orders [REDACTED]. On 12/13/19, the facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: [NAME] The policy and procedure for abuse prohibition and restraints were reviewed and Administration determined no changes were needed. B. All the following staff, Nursing Staff, Rehabilitation, Housekeeping, Kitchen, Activities, Social Services, Physicians, Physician Assistants were educated from 12/2/19 through 12/3/19 related to abuse prevention, immediately reporting abuse, resident rights and restraint usage. C. All Nursing Staff were educated regarding abuse, and if they witness abuse, then they are responsible for ensuring the incident is reported immediately. If one staff member stated that they will report the incident, then you should still report it as well because you are also responsible for ensuring it does get reported immediately. D. The Facility audited (12/02/19 through 12/03/19) all current Residents for a change in condition with behaviors and notifying and working with Psychiatric Services. E. The Facility conducted audits from 12/2/19 through 12/3/19 and ongoing verifications for all residents on every shift for risk for potential abuse and restraints. F. The Facility had an emergent Quality Assurance Improvement Committee meeting on 12/4/19 discussing the situation regarding Resident #1, what action had been taken and what interventions would be effective for similar resident behaviors of restlessness and agitation and the results of the house wide audit. H. The Director of Nurses is responsible for overall compliance. by

Based on records reviewed and interviews, for three out of four sampled residents (Resident #1, Resident #3, and Resident #4), the Facility failed to develop and or implement an individualized plan of care for sexual behaviors and/or for falls. - On [DATE], staff observed Resident #1 sitting on his/her roommate's bed (Resident #2) fondling Resident #2's genitalia. A plan of care was not developed regarding Resident #1's and Resident #2's sexual behaviors. - On [DATE], Resident #1 was verbally and physically sexually inappropriate with a Certified Nurse Aide (CNA) during toileting. - On [DATE], staff observed Resident #1 standing over Resident #2's bed masturbating as Resident #2 fondled Resident #1's genitalia. Staff did not attempt to intervene or separate Resident #1 and Resident #2, but instead left the room to report the incident to the nurse. Upon return to the room, staff observed Resident #1 performing oral sex on Resident #2 while Resident #2 fondled Resident #1's genitalia. Staff said as they separated Resident #1 from Resident #2, Resident #1 ejaculated. - On [DATE] at approximately 5:00 A.M., Resident #3 was found on the floor by CNA #6. Resident #3 was transferred to the hospital, where evaluations determined that his/her injuries included, but were not limited to: hemorrhages and contusions (bruising) in the brain, facial fractures, and facial hematomas (a solid swelling of clotted blood within the tissues). Resident #3 died on [DATE]. Findings include: The Facility policy titled, Person Centered Care Plan, revised [DATE], indicated that care plans would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals; and documented on the Care Plan Evaluation Note. 1. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated that Resident #1 was found sitting on his/her roommates (Resident #2) bed and the roommate's (Resident #2) brief had been unfastened. The Note indicated that staff moved Resident #1 closer to the nursing station for monitoring. An Event Summary Report for Resident #2, dated [DATE], indicated that it was brought to the attention of the Unit Manager (UM), the Center's Nurse Executive (CNE), and the Center's Executive Director (CED) that Resident #1 was noted sitting on Resident #2's bed two days earlier during the 11:00 P.M. to 7:00 A.M. shift on [DATE] into [DATE]. The Report indicated that when a CNA was conducting rounds, the CNA observed Resident #1 sitting on Resident #2's bed, Resident #2's brief was undone, and Resident #1 was touching Resident #2's genitalia. The Report indicated that the CNA separated Resident #1 and Resident #2 and reported the incident to the nurse. The Surveyor interviewed CNA #1 at 11:52 A.M. on [DATE] and at 9:49 A.M. on [DATE]. CNA #1 said the written statement dated [DATE] was what she had observed between Resident #1 and Resident #2 during the 11:00 P.M. to 7:00 A.M. shift on [DATE]. CNA #1 said that sometime between 12:30 A.M. and 3:30 A.M., she walked into Resident #1's and Resident #2's room and observed Resident #1 sitting on Resident #2's bed. CNA #1 said Resident #2's bed sheet was off, his/her incontinence brief was open, and Resident #1 was playing with Resident #2. CNA #1 said she got the impression that Resident #1 was touching Resident #2's genitalia. The Surveyor interviewed Nurse #1 at 3:42 P.M. on [DATE] and at 2:35 P.M. on [DATE]. Nurse #1 said that on [DATE] at a time she could not recall, CNA #1 reported to her that she observed Resident #1 sitting on Resident #2's bed, and that Resident #2's brief was undone. Nurse #1 said CNA #1 said Resident #2's brief had been changed on first rounds and that she had fastened the brief. Nurse #1 said she could not recall if CNA #1 reported that Resident #1 was touching Resident #2's genitalia. Nurse #1 said she went to the room to check on Resident #1 and Resident #2, and observed Resident #1 lying in his/her bed masturbating. Nurse #1 said Resident #1 said to her you need to finish this or words to that effect gesturing towards his/her genitalia while he/she was masturbating. Nurse #1 said she brought Resident #1 out to the nursing station for closer monitoring. Nurse #1 said she reported to Nurse #2 that Resident #1 was sitting on Resident #2's bed and Resident #2's brief was open. Nurse #1 said Nurse #2 replied that residents could masturbate and that it needed to be in a care plan. Nurse #1 said she did not update Resident #1's plan of care. Review of Resident #1's and Resident #2's plans of care indicated that there were no updates documented regarding evaluation of their required level of supervision or change of room location. The Surveyor interviewed CNA #2 at 2:00 P.M. on [DATE]. CNA #2 said that on [DATE], she took Resident #1 to the bathroom. CNA #2 said that when Resident #1 was in the bathroom with his/her genitalia exposed, he/she began to move his/her hips in a circular motion and told CNA #2 suck it (referring to Resident #1's genitalia) and yeah baby, or words to that effect. CNA #2 said Resident #1 then grabbed CNA #2's chest. CNA #2 said she reported to Nurse #1 that Resident #1 was frisky, or words to that effect, and that she did not elaborate nor did Nurse #1 ask her to. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on [DATE] and at 9:34 A.M. and 12:40 P.M. on [DATE]. The DON said plans of care for Resident #1 and Resident #2 should have been developed in response to the observed sexual contact on [DATE]. The Facility Investigation, dated [DATE], indicated that on [DATE] at approximately 8:00 A.M., CNA #3 and CNA #4 entered into Resident #1's and Resident #2's room and found Resident #1 and Resident #2 engaged in a sexual activity. The Surveyor interviewed CNA #3 at 7:09 A.M. on [DATE] and CNA #4 at 11:18 A.M. on [DATE]. CNA #3 and CNA #4 said that between approximately 7:30 A.M. and 8:00 A.M. on [DATE], they entered Resident #1's and Resident #2's room and observed Resident #1 naked, standing over Resident #2's bed masturbating while Resident #2 played with Resident #1's genitalia. CNA #3 and CNA #4 said they did not intervene, but instead left the room and reported the incident to Nurse #3. CNA #3 and CNA #4 said they returned to Resident #1's and Resident #2's room with Nurse #3 and observed Resident #1 with his/her mouth on Resident #2's genitalia while Resident #2 played with Resident #1's genitalia. CNA #3 and CNA #4 said Resident #1 did ejaculate. CNA #4 said Resident #1 then trapped her in the corner of the room and began thrusting his/her genitalia against her. CNA #3 and CNA #4 said Resident #1 laid naked in bed while CNA #4 provided care to him/her, and extended his/her legs out and tried to wrap his /her legs around CNA #4, CNA #3 said Resident #1 tried to pull CNA #4 on top of him/her while repeatedly saying give me your pussy, or words to that effect. CNA #3 said CNA #4 left Resident #1 in his/her bed and he/she continued to masturbate. There was no documentation to support an individualized comprehensive sexual behavior care plan was developed for either Resident #1 or Resident #2 after the incident of sexual activity on [DATE]; Resident #1 and Resident #2 exhibited additional sexualized behaviors after [DATE]. 2. Review of the Facility's Falls Management policy, revised [DATE], indicated that the facility would develop an individualized plan of care. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on [DATE] and at multiple times throughout the dates of survey. The DON said every resident of the Facility had a fall risk care plan in place, regardless of the individual's assessed risk. The DON said the resident's fall risk should also be documented on the resident's individual Visual/Bedside Kardex Report (a summary of the resident's individual care needs, including safety interventions). The DON said that because Resident #3's Visual/Bedside Kardex Report was revised following his/her fall on [DATE], she did not know if the Visual/Bedside Kardex Report in place at the time of Resident #3's fall indicated whether he/she was at risk for falls. Resident #3 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #3's Medication Review Report indicated it included a physician order, dated [DATE], for him/her to wear non-skid footwear for safety. Review of Resident #3's care plan for fall risk, initiated on [DATE], indicated that he/she was at risk for falls due to cognitive loss and a lack of safety awareness. The Care Plan did not include the physician's orders [REDACTED].#3 required with ambulation, any assistive devices he/she may have required, or any individualized, person-centered interventions. Review of Resident #3's clinical record indicated that it included conflicting information regarding Resident #3's use of an assistive device for ambulation, as well as the type of assistance device potentially required. Review of Resident #3's MDS, dated [DATE], indicated that he/she had severe cognitive impairment, exhibited signs and symptoms of [MEDICAL CONDITION], wandered, and required supervision while walking. The Surveyor interviewed CNA #6 at 10:05 A.M. on [DATE]. CNA #6 said that on a date she did not recall, she observed Resident #3 on the floor in his/her room, lying on his/her left side. CNA #6 said Resident #3's left eye was swollen shut, and called for help from the nurse, who's name she did not recall. CNA #6 said she had worked on Resident #3's unit prior to his/her fall, but was not familiar with Resident #3's individualized care needs or fall risk. The Surveyor interviewed Nurse #5 at 8:04 A.M. on [DATE]. Nurse #5 said that on [DATE] at approximately 5:00 A.M., she responded to CNA #6's yell for help, and observed Resident #3 lying on his/her left side on the floor in his/her room. Nurse #5 said the left side of Resident #3's face had swollen up, so she immobilized him/her, and left CNA #6 with Resident #3 while she went to call 911. Nurse #5 said it was hard to know which residents were considered a fall risk because the information was not always shared in report at change of shift. Review of Resident #3's Discharge Summary, dated [DATE], indicated that Resident #3 presented to the hospital on [DATE] after a fall earlier in the morning. The Summary indicated that Resident #3 sustained significant head trauma including, but not limited to: hemorrhages and contusions (bruising) in the brain, facial fractures, and facial hematomas (a solid swelling of clotted blood within the tissues). There was no documentation to support that the Facility developed and implemented an individualized plan of care for Resident #3 regarding his/her fall risk, or that assigned staff were knowledgeable regarding Resident #3's fall risk or fall risk interventions.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to prevent an incident of sexual abuse; failed to protect residents from additional incidents of sexual abuse; failed to notify staff of Resident #1's incidents of sexually inappropriate behavior; failed to develop and implement plans of care for Resident #1 and Resident #2 to prevent additional incidents of sexual abuse; and, left Resident #2 to cohabitate with Resident #1 after the first incident of sexual abuse. - On 05/29/19, staff observed Resident #1 sitting on his/her roommate's bed (Resident #2) and fondling Resident #2's genitalia. - After the incident on 05/29/19, Resident #1 and Resident #2 (who was dependent on staff for mobility) remained unsupervised roommates, and no interventions were implemented for Resident #1 or Resident #2 to prevent any additional non-consensual sexual activity. - On 05/30/19, Resident #1 was verbally and physically sexually inappropriate with a Certified Nurse Aide (CNA) during toileting, and the CNA failed to accurately report the incident to the nurse. No interventions were implemented for Resident #1 in response to his/her sexually inappropriate behavior with the CNA. - On 05/31/19, staff observed Resident #1 standing over Resident #2's bed masturbating as Resident #2 fondled Resident #1's genitalia. Staff did not attempt to intervene or separate Resident #1 and Resident #2, but instead left the room to report the incident to the nurse. Upon return to the room, staff observed Resident #1 performing oral sex on Resident #2 while Resident #2 fondled Resident #1's genitalia. Staff said Resident #1 ejaculated as he/she was separated from Resident #2. Findings include: The Facility Policy titled, Abuse Prohibition, revised 05/01/19, indicated that the Facility will prohibit abuse for all residents, and defined sexual abuse as a non-consensual sexual contact of any type with a resident, which included but was not limited to sexual harassment, sexual coercion or sexual assault. The Policy indicated that anyone who witnessed an incident of suspected abuse was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The Policy indicated that actions to prevent abuse included, but were not limited to: identifying, correcting, and intervening in situations in which abuse was more likely to occur. The Policy also indicated that the Facility would provide adequate supervision when the risk of resident-to-resident altercation was suspected. - Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. A Form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Massachusetts General Law (M.G.L.) C201D Form, dated and signed by the Physician on 05/24/19, indicated that Resident #1 lacked the capacity to make, or communicate health care decisions due to dementia. The Initial Assessment, dated 05/28/19, indicated that Resident #1 had severe cognitive impairment. The Activity of Daily Living Care Plan, dated 05/24/19, indicated that Resident #1 transferred and ambulated independently. Review of Resident #1's Nurse Progress Note, dated 05/29/19, indicated that Resident #1 was found sitting on his/her roommate's (Resident #2) bed and Resident #2's brief had been unfastened. The Note indicated staff moved Resident #1 closer to the nursing station for monitoring. It was later determined Resident #1 touched Resident #2's genitalia. - Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Massachusetts General Law (M.G.L.) C201D Form, dated and signed by the Physician in (YEAR) (the month and day were illegible), indicated Resident #2 lacked the capacity to make, or communicate health care decisions due to dementia. A Significant Change Minimum Data Set (MDS), dated [DATE], indicated that Resident #2 had severe cognitive impairment. The MDS indicated Resident #2 was non-ambulatory and required total dependence of two staff persons for bed mobility, transfers, and dressing which included how a resident put on, fastened, and took off all items of clothing. A Witness Statement, written and signed by CNA #1 dated 06/02/19, indicated that when she walked into Resident #1 and Resident #2's room, date not indicated, she observed Resident #1 sitting on Resident #2's bed. The Statement indicated that as she approached Resident #1 and Resident #2, she observed Resident #2's brief was open and Resident #1 was playing with Resident #2's genitalia. The Statement indicated that she redirected Resident #1 back to his/her bed, asked Resident #2 if he/she was okay, and that Resident #2 did not appear upset. The Statement indicated that CNA #1 reported the incident to Nurse #1. The Surveyor interviewed CNA #1 at 11:52 A.M. on 06/17/19 and at 9:49 A.M. on 06/18/19. CNA #1 said that sometime between 12:30 A.M. and 3:30 A.M. on 05/29/19, she walked into Resident #1's and Resident #2's room and observed Resident #1 sitting on Resident #2's bed. CNA #1 said Resident #2's bed sheet was off, his/her incontinence brief was open, and Resident #1 was playing with Resident #2, or words to that effect. CNA #1 said she got the impression that Resident #1 was touching Resident #2's genitalia. CNA #1 said Resident #1 attempted to unfasten Resident #2's brief as she attempted to fasten it. CNA #1 said she then walked Resident #1 to his/her bed and reported the incident to Nurse #1. A Witness Statement, written and signed by Nurse #1 dated 05/31/19, indicated that during the overnight shift on 05/29/19 into 05/30/19 (shift was actually 05/28/19 into 05/29/19), CNA #1 reported that Resident #1 was sitting on Resident #2's bed and Resident #2's brief was unfastened, but said that Resident #2's brief had been fastened during first rounds. The Statement indicated that CNA #1 reported no inappropriate contact was observed, but that when CNA #1 fastened Resident #2's brief, Resident #1 tried to open Resident #2's brief again before returning to his/her bed. The Statement indicated that Nurse #1 checked on Resident #1 and Resident #2 and Resident #2 said he/she was fine. The Statement indicated that Nurse #1 observed Resident #1 in his/her bed pleasuring him/herself, and when she asked how are you, he/she said to Nurse #1 that she needed to finish this. The Statement indicated that Nurse #1 told Resident #1 that was not what she was there for, and asked Resident #1 to go with her and sit in a recliner by the nursing station. The Statement indicated that Nurse #1 said to Resident #1 that he/she was welcome to play with his/her own equipment but that he/she should not be touching anyone else, or words to that effect. The Statement indicated Nurse #1 informed Nurse 2, wrote a note in the computer, monitored Resident #1 for the rest of the night, and then verbally informed the oncoming shift. The Surveyor interviewed Nurse #1 at 3:42 P.M. on 06/17/19 and at 2:35 P.M. on 06/18/19. Nurse #1 said that on 05/29/19 at a time she could not recall, CNA #1 reported to her that she observed Resident #1 sitting on Resident #2's bed, and that Resident #2's brief was undone. Nurse #1 said CNA #1 said Resident #2's brief had been changed and fastened on first rounds. Nurse #1 said she could not recall if CNA #1 reported that Resident #1 was touching Resident #2's genitalia. Nurse #1 said she went to the room to check on Resident #1 and Resident #2, and observed Resident #1 lying in his/her bed masturbating. Nurse #1 said Resident #1 said to her you need to finish this or words to that effect gesturing towards his/her genitalia while he/she was masturbating. Nurse #1 said she brought Resident #1 out to the nursing station for closer monitoring. Nurse #1 said she reported to Nurse #2 that Resident #1 was sitting on Resident #2's bed and that Resident #2's brief was open. Nurse #1 said Nurse #2 replied that men/women could masturbate and that you just needed to put it in a care plan. Nurse #1 said she did not update Resident #1's plan of care. Review of Resident #2's clinical record indicated that there was no documentation to support that Nurse #1 documented the incident on 05/29/19 involving Resident #1 and Resident #2 in Resident #2's clinical record, that CNA #1 reported to Nurse #1 that Resident #1 was seen sitting on Resident #2's bed and Resident #2's brief was opened, or that Resident #1 was touching Resident #2's genitalia. The Surveyor interviewed Nurse #2 at 12:27 P.M. on 06/17/19. Nurse #2 said Nurse #1 called her to report that a resident was sitting on another resident's bed, but said she could not recall who the residents were or what Nurse #1 said. Nurse #2 said she was not a supervisor, and said that if anything major happened, the Director of Nurses (DON) or Administrator was to be notified. Nurse #1 said she also reported the incident to Nurse #4, but said she did not report the incident to an immediate supervisor. The Surveyor interviewed Nurse #4 at 9:56 A.M. on 06/18/19. Nurse #4 said she was not notified in report on 05/29/19 that there had been any sexually inappropriate behaviors between Resident #1 and Resident #2. There was no documentation to support that Resident #1's or Resident #2's plan of care was revised or updated with new interventions to prevent additional incidents of non-consensual sexual activity after the incident on 05/29/19. The Surveyor interviewed CNA #2 at 2:00 P.M. on 06/17/19. CNA #2 said that on 05/30/19, she witnessed Resident #1 pushing another resident in a wheelchair. CNA #2 said that was strange for Resident #1 to be pushing another resident in a wheelchair, so she offered to take Resident #1 to the bathroom. CNA #2 said that when Resident #1 was in the bathroom with his/her genitalia exposed, he/she began to move his/her hips in a circular motion and told CNA #2 suck it (referring to Resident #1's genitalia) and yeah baby, or words to that effect. CNA #2 said Resident #1 then grabbed CNA #2's chest. CNA #2 said she reported to Nurse #1 that Resident #1 was frisky, or words to that effect, and said that she did not elaborate nor did Nurse #1 ask her to. Nurse #1 said she did not receive any reports from a staff member that Resident #1 was being frisky, or words to that effect, during personal care. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on 06/17/19 and at 9:34 A.M. and 12:40 P.M. on 06/18/19. The DON said she was not aware of the incident with Resident #1 and Resident #2 which occurred during the 11:00 P.M. to 7:00 A.M. shift on 05/29/19 until she interviewed staff regarding another incident between Resident #1 and Resident #2 which occurred on 05/31/19. The DON said Nurse #1 should have reported the incident between Resident #1 and Resident #2 that occurred on 05/29/19 to the DON or to the Administrator, and to the Physician. The DON said Nurse #1 should have also reported that incident to someone such as the Unit Manager, Social Worker, or to the DON so a care plan could be developed for Resident #1's sexual behavior. Review of the physician progress notes [REDACTED]. - Resident #1 and Resident #2 had dementia; - Resident #1 was found at side of Resident #2's bed fell ating (performing oral sex) on Resident #2 earlier that morning; - A CNA intervened and separated Resident #1 and Resident #2, however, Resident #1 then reportedly assaulted the CNA by reportedly grabbing her and pulling her down onto the bed on top of him/her; and, - that Resident #1 and Resident #2 had no memory of the earlier events secondary to baseline dementia. Review of Resident #2's physician progress notes [REDACTED].#2 tested positive for syphilis earlier this year with the decision at the time by the Health Care Proxy (HCP) not to treat. Event Summary Reports for Resident #1 and Resident #2, dated 05/31/19, indicated that CNA #3 and CNA #4 entered Resident #1 and Resident #2's room and found Resident #1 standing over Resident #2 and Resident #1 had his/her mouth on Resident #2's genitalia. The Report indicated Resident #2 was lying in bed and was holding onto Resident #1's genitalia. The Report indicated CNA #3 and CNA #4 separated Resident #1 and Resident #2 and then reported the incident immediately. However, this was not consistent with information provided by CNA #3 and CNA #4 during interview with the Surveyor. The Report indicated that after interviewing all staff it was brought to the attention of the Unit Manager (UM), the Center's Nurse Executive (CNE), and the Center's Executive Director (CED) that Resident #1 was noted sitting on Resident #2's bed two days earlier during the 11:00 P.M. to 7:00 A.M. shift on 05/28/19 into 05/29/19. The Report indicated a CNA was conducting rounds and saw Resident #1 sitting on Resident #2's bed, the CNA entered the room and noticed Resident #2's brief was undone and Resident #1 was touching Resident #2's genitalia. The Report indicated the CNA separated Resident #1 and Resident #2 and reported the incident to the nurse. The Report indicated the nurse went and checked on Resident #1 and Resident #2, and removed Resident #1 from the room for further monitoring. Witness Statements, written and signed by CNA #3 and CNA #4 dated 05/31/19, indicated that: - CNA #3 and CNA #4 walked into Resident #1's and Resident #2's room and observed Resident #2 lying in bed holding Resident #1's genitalia, and Resident #1 sucking on Resident #2's genitalia; and, - CNA #3 and CNA #4 separated Resident #1 and Resident #2 immediately. However, this was not consistent with information provided by CNA #3 and CNA #4 during interview with the Surveyor that they did not immediately separate Resident #1 and Resident #2. The Statements also indicated that: - after CNA #3 and CNA #4 observed Resident #1 sucking on Resident #2's genitalia, Resident #1 tried to push CNA #3 out the door; - when CNA #4 approached Resident #1 to provide care, he/she pushed CNA #4 into the corner and thrust his/her genitalia against CNA #4; - Resident #1 then backed up, laid down onto his/her bed, put his/her legs around CNA #4 and tried to pull CNA #4 on top of him/herself; - CNA #3 pulled Resident #1's legs apart so CNA #4 could get away; and, - after CNA #3 and CNA #4 reported the incident to Nurse #3, they returned to the room with Nurse #3, who stood outside the door and said come on guys let's stop, or words to that effect, and then returned to the nursing station. The Surveyor interviewed CNA #3 at 7:09 A.M. on 06/18/19 and CNA #4 at 11:18 A.M. on 06/18/19. CNA #3 and CNA #4 said that between approximately 7:30 A.M. and 8:00 A.M. on 05/31/19, they entered Resident #1's and Resident #2's room and observed Resident #1 naked, standing over Resident #2's bed masturbating while Resident #2 played with Resident #1's genitalia. CNA #3 and CNA #4 said they did not intervene, but instead left the room and reported the incident to Nurse #3. CNA #3 and CNA #4 said they returned to Resident #1's and Resident #2's room with Nurse #3 and observed Resident #1 with his/her mouth on Resident #2's genitalia while Resident #2 played with Resident #1's genitalia. CNA #3 said Nurse #3 separated Resident #1 and Resident #2 and Resident #1 then ejaculated everywhere, or words to that effect. CNA #4 said Resident #1 ejaculated as she walked him/her back to his/her bed, and then trapped her in the corner of the room and began thrusting his/her genitalia against her. CNA #3 and CNA #4 said Resident #1 lay naked in bed while CNA #4 provided care to him/her, and extended his/her legs out and tried to wrap his /her legs around CNA #4. CNA #3 said Resident #1 tried to pull CNA #4 on top of him/her while repeatedly saying give me your pussy, or words to that effect. A Witness Statement, written and signed by Nurse #3 dated 05/31/19, indicated that: - after the incident happened, CNA #3 and CNA #4 reported to her that one resident was over another resident and they were touching each other's genitalia; - she went to the room and observed Resident #1 sucking on Resident #2's genitalia and Resident #2 playing with Resident #1's genitalia. However, this is not consistent with information provided by Nurse #3 during interview with the Surveyor. The Surveyor interviewed Nurse #3 at 3:10 P.M. on 06/18/19. Nurse #3 said that sometime in the morning on 05/31/19, two CNAs who's names she could not recall, reported to her that Resident #1 and Resident #2 were engaged in inappropriate activity. Nurse #3 said she went to the room with the CNAs and observed Resident #2 lying naked in bed with Resident #1 hovering naked over Resident #2's bed. Nurse #3 said she did not see Resident #1 with Resident #2's genitalia in his/her mouth, which contradicted what she wrote in her signed statement. Nurse #3 said she only observed Resident #1 hovering over Resident #2's genitalia and observed Resident #2's hands near Resident #1's genitalia. Nurse #3 said that when she knocked on the door prior to entering Resident #1's and Resident #2's room, Resident #1 walked away from Resident #2 and back to his/her side of the room. The Director of Nurses (DON) said Resident #1 and Resident #2 both had dementia and lacked the capacity to consent to sexual activity. The Surveyor interviewed Physician #1 at 11:10 A.M. and at 3:19 P.M. on 06/17/19. Physician #1 said Resident #1 and Resident #2 both had advanced dementia with impulsive behaviors and lacked the capacity to consent to sexual activity.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to implement their abuse prohibition policy. - On 05/29/19, the Facility staff failed to follow their policy to report to an immediate supervisor when staff observed Resident #1 sitting on his/her roommate's bed (Resident #2) and fondling Resident #2's genitalia. - On 05/31/19, the Facility staff failed to follow their policy and immediately intervene when staff observed Resident #1 standing over Resident #2's bed masturbating as Resident #2 fondled Resident #1's genitalia. Staff did not attempt to intervene or separate Resident #1 and Resident #2, but instead left the room to report the incident to the nurse. Upon return to the room, staff observed Resident #1 performing oral sex on Resident #2 while Resident #2 fondled Resident #1's genitalia. Staff said Resident #1 ejaculated as they separated him/her from Resident #2. Findings include: The Facility Policy titled, Abuse Prohibition, revised 05/01/19, indicated that that Sexual Abuse was a non-consensual sexual contact of any type with a resident. The Policy indicated that anyone who witnessed an incident of suspected abuse was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The Policy indicated that the notified supervisor will report the suspected abuse immediately to the Center Executive Director or designee and other officials in accordance with state law. The Policy indicated to notify local law enforcement, Licensing Boards and Registries, and other agencies as required. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. 1. Review of Resident #1's Nurse Progress Note, dated 05/29/19, indicated that Resident #1 was found sitting on his/her roommate's (Resident #2) bed and Resident #2's brief had been unfastened. The Note indicated that staff moved Resident #1 closer to the nursing station for monitoring. Review of Resident #2's clinical record indicated there was no documentation to support that Nurse #1 documented the incident on 05/29/19 between Resident #1 and Resident #2. An Event Summary Report for Resident #2, dated 05/31/19, indicated that after interviewing all staff it was brought to the attention of the Unit Manager (UM), the Center's Nurse Executive (CNE), and the Center's Executive Director (CED) that Resident #1 was noted sitting on Resident #2's bed two days earlier during the 11:00 P.M. to 7:00 A.M. shift on 05/28/19 into 05/29/19. The Report indicated that when a CNA entered Resident #1's and Resident #2's room, the CNA observed that Resident #2's brief was undone and Resident #1 was touching Resident #2's genitalia. The Report indicated that the CNA separated Resident #1 and Resident #2 and reported the incident to the nurse. The Report indicated the nurse went and checked on Resident #1 and Resident #2 and removed Resident #1 from the room for further monitoring. A Witness Statement, written and signed by CNA #1 dated 06/02/19, indicated that when she walked into Resident #1 and Resident #2's room, date not indicated, she observed Resident #1 sitting on Resident #2's bed. The Statement indicated that as she approached Resident #1 and Resident #2, she observed Resident #2's brief was open and Resident #1 was playing with Resident #2's genitalia. The Statement indicated that she redirected Resident #1 back to his/her bed, asked Resident #2 if he/she was okay, and that Resident #2 did not appear upset. The Statement indicated that CNA #1 reported the incident to Nurse #1. The Surveyor interviewed CNA #1 at 11:52 A.M. on 06/17/19 and at 9:49 A.M. on 06/18/19. CNA #1 said the written statement dated 06/02/19 was what she had observed between Resident #1 and Resident #2 during the 11:00 P.M. to 7:00 A.M. shift on 05/29/19. CNA #1 said that sometime between 12:30 A.M. and 3:30 A.M., she walked into Resident #1's and Resident #2's room and observed Resident #1 sitting on Resident #2's bed. CNA #1 said Resident #2's bed sheet was off, his/her incontinence brief was open, and Resident #1 was playing with Resident #2. CNA #1 said she got the impression that Resident #1 was touching Resident #2's genitalia. CNA #1 said that as she fastened Resident #2's brief, Resident #1 attempted to unfasten Resident #2's brief. CNA #1 said she then walked Resident #1 to his/her bed and reported the incident to Nurse #1. A Witness Statement, written and signed by Nurse #1 dated 05/31/19, indicated that during the overnight shift on 05/29/19 into 05/30/19 (shift was actually 05/28/19 into 05/29/19), CNA #1 reported that Resident #1 was sitting on Resident #2's bed and Resident #2's brief was unfastened, but that Resident #2's brief had been fastened during first rounds. The Statement indicated that CNA #1 reported no inappropriate contact was observed, but that when CNA #1 fastened Resident #2's brief, Resident #1 tried to open Resident #2's brief again before returning to his/her bed. The Statement indicated that Nurse #1 said to Resident #1 that he/she was welcome to play with his/her own equipment but that he/she should not be touching anyone else, or words to that effect. The Statement did not indicate whether Nurse #1 informed the supervisor, Director of Nurses (DON; CNE), the physician, or Administrator or designee of the incident between Resident #1 and Resident #2. The Surveyor interviewed Nurse #1 at 3:42 P.M. on 06/17/19 and at 2:35 P.M. on 06/18/19. Nurse #1 said that on 05/29/19 at a time she could not recall, CNA #1 reported to her that she observed Resident #1 sitting on Resident #2's bed, and that Resident #2's brief was undone. Nurse #1 said CNA #1 said Resident #2's brief had been changed on first rounds and that she had fastened the brief. Nurse #1 said she could not recall if CNA #1 reported that Resident #1 was touching Resident #2's genitalia. Nurse #1 said she reported to Nurse #2 that Resident #1 was sitting on Resident #2's bed and Resident #2's brief was open. The Surveyor interviewed Nurse #2 at 12:27 P.M. on 06/17/19. Nurse #2 said Nurse #1 called her to report that a resident was sitting on another resident's bed, but said she could not recall who the residents were or what Nurse #1 said. Nurse #2 said she is not a supervisor, that each nurse during the 11:00 P.M. to 7:00 A.M. shift was responsible for their own floors. Nurse #2 said that if anything major happened, the Director of Nurses (DON) or Administrator were to be called. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on 06/17/19 and at 9:34 A.M. and 12:40 P.M. on 06/18/19. The DON said Nurse #1 should have reported the incident between Resident #1 and Resident #2 that occurred on 05/29/19 to the DON or to the Administrator, and to the Physician. There was no documentation to support that the Center Executive Director or designee were notified of the incident of sexually inappropriate behavior between Resident #1 and Resident #2 on 05/29/19; or that other officials, including law enforcement, were notified in accordance with state law. 2. A Situation Background Appearance Review and Notify (SBAR) Communication Form, dated 05/31/19 (two days after the first sexual incident between Resident #1 and Resident #2), indicated that Resident #1 was found engaged in a sexual activity with his/her roommate (Resident #2). An Event Summary Report for Resident #2, dated 05/31/19, indicated thatCNA #3 and CNA #4 separated Resident #1 and Resident #2, and then reported the incident immediately. However, this was not consistent with information provided by CNA #3 and CNA #4 during interview with the Surveyor. The Surveyor interviewed CNA #3 at 7:09 A.M. on 06/18/19 and CNA #4 at 11:18 A.M. on 06/18/19. CNA #3 and CNA #4 said that between approximately 7:30 A.M. and 8:00 A.M. on 05/31/19, they entered Resident #1's and Resident #2's room and observed Resident #1 naked, standing over Resident #2's bed masturbating while Resident #2 played with Resident #1's genitalia. CNA #3 and CNA #4 said they did not intervene, but instead left the room and reported the incident to Nurse #3. CNA #3 and CNA #4 said they returned to Resident #1's and Resident #2's room with Nurse #3 and observed Resident #1 with his/her mouth on Resident #2's genitalia while Resident #2 played with Resident #1's genitalia. CNA #3 said Nurse #3 separated Resident #1 and Resident #2. The Surveyor interviewed Nurse #3 at 3:10 P.M. on 06/18/19. Nurse #3 said that sometime in the morning on 05/31/19, two CNAs who's names she could not recall, reported to her that Resident #1 and Resident #2 were engaged in inappropriate activity. Nurse #3 said she went to the room with the CNAs and observed Resident #2 naked lying in bed with Resident #1 naked hovering over Resident #2's bed. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on 06/17/19 and at 9:34 A.M. and 12:40 P.M. on 06/18/19. The DON said CNA #3 and CNA #4 did not intervene and separate Resident #1 and Resident #2 and that they should have, but instead went to get Nurse #3. The DON said Resident #1 and Resident #2 both had dementia and lacked the capacity to consent to sexual activity because they did not know what was going on in their minds. The DON said she did not report the inappropriate sexual activity incident that occurred on 05/31/19 between Resident #1 and Resident #2 to the police.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that an alleged incident of sexual abuse was reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. - On 05/29/19, staff observed Resident #1 sitting on his/her roommate's bed (Resident #2) and fondling Resident #2's genitalia. - On 05/31/19, staff observed Resident #1 standing over Resident #2's masturbating as Resident #2 fondled Resident #1's genitalia. Staff did not attempt to intervene or separate Resident #1 and Resident #2, but instead left the room to report the incident to the nurse. Upon return to the room, staff observed Resident #1 performing oral sex on Resident #2 while Resident #2 fondled Resident #1's genitalia. Staff said Resident #1 ejaculated as as they separated him/her from Resident #2. Findings include: The Facility Policy titled, Abuse Prohibition, revised 05/01/19, indicated that the Facility will prohibit abuse for all residents, and defined sexual abuse as a non-consensual sexual contact of any type with a resident, which included but was not limited to sexual harassment, sexual coercion or sexual assault. The Policy indicated that anyone who witnessed an incident of suspected abuse was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The Policy indicated that the notified supervisor would report the suspected abuse immediately to the Center Executive Director or designee, and other officials in accordance with state law. The Policy indicated that staff were to notify local law enforcement, Licensing Boards and Registries, and other agencies as required. - Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. A Form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Massachusetts General Law (M.G.L.) C201D Form, dated and signed by the Physician on 05/24/19, indicated that Resident #1 lacked the capacity to make, or communicate health care decisions due to dementia. The Initial Assessment, dated 05/28/19, indicated that Resident #1 had severe cognitive impairment. - Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Massachusetts General Law (M.G.L.) C201D Form, dated and signed by the Physician in (YEAR) (the month and day were illegible), indicated Resident #2 lacked the capacity to make, or communicate health care decisions due to dementia. A Significant Change Minimum Data Set (MDS), dated [DATE], indicated that Resident #2 had severe cognitive impairment. The Surveyor interviewed CNA #1 at 11:52 A.M. on 06/17/19 and at 9:49 A.M. on 06/18/19. CNA #1 said that sometime between 12:30 A.M. and 3:30 A.M., during the 11:00 P.M. to 7:00 A.M. shift on 05/29/19, she walked into Resident #1's and Resident #2's room and observed Resident #1 sitting on Resident #2's bed. CNA #1 said Resident #2's bed sheet was off, his/her incontinence brief was open, and Resident #1 was playing with Resident #2. CNA #1 said she got the impression that Resident #1 was touching Resident #2's genitalia. CNA #1 said that as she fastened Resident #2's brief, Resident #1 attempted to unfasten Resident #2's brief. CNA #1 said she then walked Resident #1 to his/her bed and reported the incident to Nurse #1. The Surveyor interviewed Nurse #1 at 3:42 P.M. on 06/17/19 and at 2:35 P.M. on 06/18/19. Nurse #1 said that on 05/29/19 at a time she could not recall, CNA #1 reported to her that she observed Resident #1 sitting on Resident #2's bed, and that Resident #2's brief was undone. Nurse #1 said she did not report the incident to an immediate supervisor. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on 06/17/19 and at 9:34 A.M. and 12:40 P.M. on 06/18/19. The DON said she was not aware of the incident with Resident #1 and Resident #2 which occurred during the 11:00 P.M. to 7:00 A.M. shift on 05/29/19 until she interviewed staff regarding another incident between Resident #1 and Resident #2 which occurred two days later. The DON said Nurse #1 should have immediately reported the incident between Resident #1 and Resident #2 that occurred on 05/29/19 to the Administrator or designee. There was no documentation to support that the DON, Administrator or designee, or law enforcement were notified of the alleged incident of sexual abuse on 05/29/19 involving Resident #1 and Resident #2.

Based on records reviewed, interviews, and observations, for one of four sampled residents (Resident #3), the facility failed to prevent a fall through the identification and assessment of the individual resident's risks; failed to identify and implement measures to reduce the risks as much as possible; and, failed to ensure a resident's fall risk status was communicated to caregivers. - On [DATE] at approximately 5:00 A.M., Resident #3 was found on the floor by Certified Nurse Aide (CNA) #6. Resident #3 was transferred to the hospital, where evaluations determined that his/her injuries included, but were not limited to: hemorrhages and contusions (bruising) in the brain, facial fractures, and facial hematomas (a solid swelling of clotted blood within the tissues). Resident #3 expired on [DATE]. Findings include: The Surveyor interviewed CNA #6 at 10:05 A.M. on [DATE]. CNA #6 said that on a date she could not recall, she observed Resident #3 on the floor in his/her room, lying on his/her left side. CNA #6 said Resident #3's left eye was swollen shut, and called for help from the nurse, who's name she did not recall. CNA #6 said she had worked on Resident #3's unit prior to his/her fall, but was not familiar with Resident #3's care needs. CNA #6 said she did not know if Resident #3 was at risk for falls prior to the incident on [DATE]. The Surveyor interviewed Nurse #5 was interviewed at 8:04 A.M. on [DATE]. Nurse #5 said she was working on Resident #3's unit on the date and time that he/she fell . Nurse #5 said that at approximately 5:00 A.M., she heard CNA #6 yell for her. Nurse #5 said she ran down the hall to Resident #3's room, and observed him/her lying on his/her left side on the floor in his/her room. Nurse #5 said the left side of Resident #3's face was swollen up, so she immobilized him/her, and left CNA #6 with Resident #3 while she went to call 911. Nurse #5 said Resident #3 was awake and vocalizing, but said his/her speech was garbled, which Nurse #5 said she did not know if that was normal for Resident #3. Nurse #5 said it was hard to know which residents were considered a fall risk. Nurse #5 said sometimes a resident's fall risk was shared in report at change of shift, but not always. Nurse #5 said Resident #3 was not a fall risk because he/she could walk without assistance. Review of the Facility's Falls Management policy, revised [DATE], indicated that residents would be assessed for falls risk as part of the nursing assessment process; communicate a resident's fall risk status to caregivers; and, develop an individualized plan of care. Resident #3 was admitted to the Facility in (MONTH) 2019 for respite care with [DIAGNOSES REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on [DATE] and at multiple times throughout the dates of survey. The DON said she did not know how the fall risk score was calculated from the Nursing Assessments in the residents' electronic health records. The DON later provided the Surveyor with the Fall Risk Score Calculations, effective [DATE]. Review of the Fall Risk Score Calculations indicated that a resident's fall risk score was calculated based on the response to five questions, and that a score of 12 or more indicated that a resident was at high risk for falls. However, two of the five questions included in the scoring were questions regarding Resident #3's fall history that were coded as unable to determine on both Resident #3's Nursing Assessment - Initial (Admission) effective [DATE], and Resident #3's Nursing Assessment - Expanded (MDS Adm./Qrtly/Annual/Sig. Change) effective [DATE]. The Calculations also included medications received by the resident which factored into the score, including but not limited to, antihypertensives (medications for high blood pressure) and diuretics (medications used to treat fluid retention). The DON said she did not know if not coding a question, or coding a question as unable to determine, would impact a resident's overall fall risk score. Review of Resident #3's Nurse Practitioner Progress Note, dated [DATE], indicated that Resident #3 had received [MEDICATION NAME] (a diuretic medication used to treat high blood pressure and fluid retention) and [MEDICATION NAME] (a medication used to treat high blood pressure) since approximately (MONTH) (YEAR). Review of Resident #3's Nursing Assessment - Initial (Admission), effective [DATE], indicated that it included three questions regarding his/her fall history in the six months prior to admission/entry or reentry. The Assessment indicated that the three questions were coded as unable to determine, but also indicated that Resident #3's fall risk score was an eight. The Assessment did not indicate that Resident #3 received a diuretic medication, which would have increased Resident #3's fall risk. Review of Resident #3's Medication Review Report indicated it included a physician order, dated [DATE], for him/her to wear non-skid footwear for safety. Review of Resident #3's care plan for fall risk, initiated on [DATE], indicated that he/she was at risk for falls due to cognitive loss and a lack of safety awareness. The Care Plan did not include the physician's orders [REDACTED].#3 required with ambulation, any assistive devices he/she may have required, or any individualized, person-centered interventions. Review of Resident #3's Nursing Assessment - Expanded (MDS Adm./Qrtly/Annual/Sig. Change), effective [DATE], indicated that it included eight questions regarding his/her fall history in the six months prior to admission/entry or reentry. The Assessment indicated that three of the questions were coded as unable to determine and three were not coded at all, but also indicated that Resident #3's fall risk score was a nine. The Assessment did not indicate that Resident #3 received a diuretic medication, which would have increased Resident #3's fall risk. Review of Resident #3's Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, exhibited signs and symptoms of [MEDICAL CONDITION],and wandered. The MDS indicated that Resident #3 required supervision while walking, but also indicated that Resident #3 used a wheelchair. The MDS also indicated that Resident #3 received a diuretic seven out of the seven days prior to the date of the MDS. Review of Resident #3's Nursing Progress Note, dated [DATE] at 20:13 (8:13 P.M.), indicated that Resident #3 was self-propelling around the unit in a wheelchair. Review of Resident #3's Nursing Progress Note, dated [DATE] at 21:21 (9:21 P.M.), indicated that Resident #3 was about the unit in his/her walker. Review of the Documentation Survey Report for (MONTH) 2019 indicated that from [DATE] through [DATE], Resident #3's level of assistance for walking varied from being independent to requiring limited physical assistance. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #3 ambulated with supervision, without the use of an assistive device. - The DON said that if an individual resident's fall risk was not passed on in report at change of shift, licensed nurses would have to review the individual resident's clinical record to determine that information. The DON said that CNAs should also be told in report what a resident's fall risk was, and said the resident's fall risk should be documented on the resident's Kardex (a summary of a resident's care needs, including level of assistance required with care needs). The DON said that effective [DATE], seven days prior to Resident #3's fall, Facility staff began using new electronic forms which could be used for multiple purposes, including initial admission or readmission assessments, or for nursing progress notes. The DON said that the new electronic forms did not allow for the consistent identification of whether a resident was identified as a fall risk. The Surveyor interviewed Nurse #1 at 3:42 P.M. on [DATE] and at multiple times throughout the dates of survey. Nurse #1 said the only way she would know if a resident was at risk for falls was if the information was shared at report during change of shift, or if she went into the individual resident's clinical record specifically to look for that information. The DON said Resident #3's Visual/Bedside Kardex Report (a summary of a resident's individual care needs, including safety interventions) provided to the Surveyor at the time of survey was updated after Resident #3's fall on [DATE]. The DON said that because Resident #3's Visual/Bedside Kardex Report was updated after his/her fall, any prior versions of the document were unavailable and so she did not know the Visual/Bedside Kardex in place prior to Resident #3's fall included any safety interventions or his/her fall risk. Review of Resident #3's Visual/Bedside Kardex Report, undated, indicated that it did include safety interventions, but did not include Resident #3's fall risk status. Review of Resident #3's Discharge Summary, dated [DATE], indicated that Resident #3 presented to the hospital on [DATE] after a fall earlier in the morning. The Summary indicated that Resident #3 sustained significant head trauma including: - Small anterior falx subdural hematoma (a collection of blood, usually caused by severe head injuries, in the membrane between the two halves of the brain); - Intraventricular hemorrhage (bleeding inside or around the ventricles (the spaces in the brain that contain the cerebral spinal fluid) in the brain); - Small right frontal lobe hemorrhagic contusion (bruising of the brain tissue in the front of the brain, common in the setting of significant head injury); - Right posterior temporal lobe subarachnoid hemorrhage (sudden bleeding in the space surrounding the brain located behind the ears); - Comminuted depressed left orbital floor fracture (a [MEDICAL CONDITION] of the eye socket which resulted in the multiple bone fragments which are pressed below their normal surface) with left maxillary sinus (sinus located below the cheeks, above the teeth and on the sides of the nose) hemorrhage and herniation of the orbital fat (fat around the eye), with displacement of the fracture fragments of at least five millimeters (approximately 0.2 inch); - Moderate left orbital, maxillary and mandibular hematoma (area from the eye down to the lower jaw); and, an - Oblique displaced [MEDICAL CONDITION] fifth metacarpal shaft (an angular [MEDICAL CONDITION] of the pinky finger in which the fragments of bone are offset). The Discharge Summary also indicated that Resident #3's Health Care Proxy declined trauma care, and that Resident #3 was admitted to ensure comfort and then transitioned to hospice at the Facility. Review of Resident #3's clinical record indicated that he/she was pronounced dead on [DATE]. There was no documentation to support that the Facility obtained Resident #3's falls history, accurately coded assessments used to determine Resident #3's fall risk, developed and implemented an individualized plan of care for his/her fall risk; or, ensured that his/her fall risk was communicated with his/her caregivers.

Based on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to notify Resident #1 and Resident #2's Physician of a significant incident. On 05/29/19, staff observed Resident #1 sitting on his/her roommate's (Resident #2) bed, Resident #2's brief was unfastened, and Resident #1 was touching Resident #2's genitalia. Findings include: The Facility Policy titled, Notification of Change in Condition, dated 11/28/16, indicated that the Facility must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care decision Maker (HCDM), where there is a significant change in the patients physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 05/29/19, indicated Resident #1 was found sitting on his/her roommate's (Resident #2) bed and Resident #2's brief had been unfastened. The Note indicated staff moved Resident #1 closer to the nursing station for monitoring. A Witness Statement, written and signed by Certified Nurse Aide (CNA) #1, dated 06/02/19, indicated when she walked into Resident #1 and Resident #2's room, she observed Resident #1 sitting on Resident #2's bed and observed Resident #2's brief opened and Resident #1 was touching Resident #2's genitalia. The Statement indicated she reported the incident to Nurse #1. The Surveyor interviewed CNA #1 at 11:52 A.M. on 06/17/19 and at 9:49 A.M. on 06/18/19. CNA #1 said on 05/29/19 during the 11:00 P.M. to 7:00 A.M. shift, sometime between 12:30 A.M. and 3:30 A.M., she walked into their room and saw Resident #1 sitting on Resident #2's bed, Resident #2's bed sheet was off, his/her brief was open, and Resident #1 was touching Resident #2. A Witness Statement, written and signed by Nurse #1, dated 05/31/19, indicated while working the overnight shift on 05/28/19 into 05/29/19 (shift was actually 05/29/19 into 05/30/19), CNA #1 reported that Resident #1 was sitting on Resident #2's bed and Resident #2's brief was unfastened. The Statement indicated CNA #1 reported Resident #2's brief had been fastened during the first rounds. The Statement indicated as CNA #1 fastened Resident #2's brief, Resident #1 tried to open Resident #2's brief again before returning to his/her bed. The Surveyor interviewed Nurse #1 at 3:42 P.M. on 06/17/19 and at 2:35 P.M. on 06/18/19. Nurse #1 said on 05/29/19, could not recall what time, CNA #1 reported to her that she had observed Resident #1 sitting on Resident #2's bed and that Resident #2's brief was undone. Nurse #1 could not recall if CNA #1 had reported that Resident #1 was touching Resident #2's genitalia. Nurse #1 said she did not report the incident to the Physician. Review of Resident #1 and Resident #2's clinical record indicated there was no documentation to support that their Physician's had been notified of the incident on 05/29/19. The Surveyor interviewed Physician #1 at 11:10 A.M. and at 3:19 P.M. on 06/17/19. Physician #1 said he was not made aware of the incident between Resident #1 and Resident #2 on 05/29/19. The Surveyor interviewed the Director of Nurses (DON) at 4:38 P.M. on 06/17/19 and at 9:34 A.M. and 12:40 P.M. on 06/18/19. The DON said Nurse #1 should have reported the incident between Resident #1 and Resident #2 that occurred on 05/29/19 during the 11:00 P.M. to 7:00 A.M. shift to the DON or to the Administrator and to the Physician.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to nursing staff followed acceptable standards of practice, when nursing did not thoroughly assess Resident #1 for a [MEDICAL CONDITION] it was reported that he/she had spilled hot coffee on him/herself. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Facility Policy, titled Physician/Advanced Practice Provider (APP) Notification, revised 12/01/18, indicated upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations, and collect pertinent patient information such as age, diagnoses, prior vital signs, labs, recent changes in medications, previous incidents of similar nature, code status, etc. and report to physician/advanced practice practitioner. Resident #1 was admitted to the Facility in (MONTH) (YEAR). The Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy ACT M.G.L. C201D, dated 09/15/15, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions, and that his/her Health Care Proxy was invoked. The Facility Investigation, dated 01/10/19 (five days after the incident), indicated Resident #1 was observed on 01/05/19 by Activity Aide #1 to have spilled hot coffee on his/her chest. The Investigation indicated Nurse #1 assessed Resident #1 and noted a red area on his/her chest, thought the area looked fungal in nature and Nurse #1 did not note any coffee spilled on Resident #1's shirt. The Investigation indicated Nurse Practitioner #2 assessed Resident #1 on 01/07/19 (2 days after the incident) and prescribed [MEDICATION NAME] cream (an antifungal cream for a fungal infection). Review of Resident #1's medical record indicated there was no documentation to support that Nurse #1 completed a thorough skin assessment on Resident #1 after it had been reported to her that Resident #1 had spilled hot coffee on him/herself. A Nurse Practitioner Note, dated 01/07/19, indicated Resident #1 had a diffuse, flat, [DIAGNOSES REDACTED]tous (red) area on center of chest and questioned a fungal rash. A Nurse Practitioner Note, dated 01/09/19, indicated Resident #1 had a diffuse, flat, [DIAGNOSES REDACTED]tous (red) area on center of chest. The Note indicated nursing reported that, over the weekend, Resident #1 had spilled coffee on his/her chest and questioned a second degree burn (partial thickness). A Wound Consult Report, dated 01/10/19, indicated Resident #1 had a third degree burn (full thickness) on his/her chest area. The Surveyor interviewed Activity Aide #1 at 8:52 A.M. on 02/12/19. Activity Aide #1 said on 01/05/19 that Resident #1 had spilled hot coffee on him/herself and that Resident #1 had reported that his/her chest hurt. Activity Aide #1 said she reported this to Nurse #1. Activity Aide #1 said she gave Resident #1 a damp cloth for his/her legs and chest and changed his/her socks. The Surveyor interviewed Nurse #1 at 2:22 P.M. on 02/12/19. Nurse #1 said she was notified by Activity Aide #1 that Resident #1 had spilled hot coffee on him/herself. Nurse #1 said she did not note any spilled coffee on Resident #1 clothes. Nurse #1 said she peeked at Resident #1's chest and noted a pink area and thought it was a fungal rash. Nurse #1 said she did not remove Resident #1's clothes to do a complete skin assessment. Nurse #1 said she did not render first aide to Resident #1. Nurse #1 said she did not notify Resident #1's attending physician, nurse practitioner or responsible person. Nurse #1 said she did not document the incident or report to the next nurse on duty that that Resident #1 has spilled hot coffee on him/herself. The Surveyor interviewed Nurse Practitioner #2 at 8:36 A.M. on 02/12/19. Nurse Practitioner #2 said she was notified on 01/07/19 that Resident #1 had a reddened area on his/her chest, was not informed at the time that Resident #1 had spilled hot coffee on him/herself on 01/05/19 and ordered [MEDICATION NAME] cream. Nurse Practitioner #2 said that it wasn't until 01/09/19 that she was informed (could not recall how or who informed her) that Resident #1 had spilled hot coffee on him/herself and at that time she discontinued the [MEDICATION NAME] cream and ordered wound gel. Nurse Practitioner #2 said if she had been informed that Resident #1 had spilled hot coffee on his/her chest she would have ordered a different treatment on 01/07/19. The Surveyor interviewed Nurse Practitioner #1 at 2:10 P.M. on 02/12/19. Wound Nurse Practitioner #1 said she assessed Resident #1 on 01/10/19 and said that Resident #1 had suffered a third degree burn on his/her chest and that it was not a fungal rash. Nurse Practitioner #1 said a delay in treatment to a burn or applying [MEDICATION NAME] cream to a burn could make a burn worse. The Surveyor interviewed the Director of Nurses (DON) at 1:22 P.M. on 02/12/19. The DON said Nurse #1 did not document in Resident #1's clinical record that he/she had spilled hot coffee on him/herself. The DON said Nurse #1 did not notify Resident #1's attending physician, nurse practitioner, or responsible person on 01/05/19 that he/she had spilled hot coffee on him/herself. Past Non-Compliance: On 02/12/19, the Facility was found to be in past non-compliance. In response to the incident, the Facility took the following action: A) Resident #1's plan of care was updated on 01/10/19 to ensure all hot beverages have a lid. B) Resident #1's burn to his/her chest resolved on 01/31/19. C) The Facility did not identify any other resident that had sustained a burn from a hot beverage. D) Staff Education was completed on 01/10/19, on Resident #1's updated plan of care to ensure all hot beverages to be in a cup with a lid. E) Staff Education was provided to nursing staff, social services and activity staff on burns, what to do if a resident spills a hot beverage on themselves, conducting a skin assessment, documentation, first aid, and notification to the physician and responsible person and was completed on 01/26/19. F) Residents that experience a change of condition or had an accident/incident report completed were being reviewed in morning meeting daily to ensure documentation was completed and that the physician and responsible persons were notified. G) Temperature Logs were being submitted to the Administrator for review at the monthly Quality Assurance Performance Improvement (QAPI) meeting. The Monthly QAPI meeting was held on 01/16/19 and the results of the audits and Resident #1's burn were reported to the committee.

Based on observation, record review, and staff interviews, the Facility failed to ensure that 3 of 12 applicable residents with falls ( #4, #8, #18), out of a total sample of 24 residents, received adequate assistive devices and/or supervision to prevent accidents with injury. Additionally, the Facility failed to maintain a hazard-free environment for 3 of 3 units (Transitional Care Unit, Leeds Unit and the Long Term Care Unit), in resident rooms/bathrooms as it related to the storage of chemical hazards. Findings include: 1. For Resident #4, the facility did not provide supervision, and assistive devices to prevent 3 falls which resulted in injury (a fractured shoulder, radius and ulna, and laceration with sutures), from 3/19/15 to present. Resident #4 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. A care plan to have no falls due to risk for falls, cognitive loss and lack of safety awareness, dated 3/18/15, had the following interventions: -Resident is able to ambulate short distances, needs direction and cueing related to impaired vision, -Resident to wear non-skid socks while in bed and shoes when out of bed, -Assist getting in and out of bed as needed, -Provide verbal cue for safety and sequencing as needed, -Maintain clutter-free environment in resident's room, -and Monitor for and assist for toileting needs. Record review of 3/19/15 at 10:15 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident had an unwitnessed fall when found laying on the floor on the left side and crying, reporting left arm pain. The resident was sent to the local hospital and found to have an acute fracture of the left shoulder, left radius and ulna. It was noted that the resident had bare feet and not the non-skid socks, as planned when the resident was in bed. It was recommended that the care plan be updated to include: -Ambulate with the resident with one assist, -and Have a bed alarm while in bed. Review of the 4/2016 Quarterly Minimum Data Set (MDS) Assessment indicated the resident had severely impaired vision, long and short term memory loss, was severely impaired cognitively, required extensive assistance of one for transfers, ambulation, dressing, eating, toilet use, and hygiene, was usually incontinent of bowel and always incontinent of bladder, and had fallen with major injury. Record review of 6/16/15 at 8:50 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident was observed by staff naked and walking in the hallway. The Resident was previously observed in bed. The Resident was escorted by staff to his/her bedroom. As the Resident and staff walked into the room, the Resident slid and fell to the floor. There was urine on the floor and staff did not see the pool of urine. The resident sustained [REDACTED]. Resident #4 was sent to the local hospital and received 5 sutures to the forehead. The investigation indicated the resident did not have on non-skid socks at the time. The reports did not indicate if a bed alarm was in place (as planned) and sounding. The care plan for falls was updated 7/26/15 to include an impact mat to the right side of the resident's bed. The resident's Quarterly MDS Assessment of 7/24/15 indicated the resident had fallen with major injury. The resident's Annual MDS Assessment of 10/21/15 indicated the resident was usually incontinent of bowel and bladder and had no falls since the last assessment. Record review of 11/9/15 at 5:45 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident was observed by staff walking in the hallway without staff assistance into another resident's wheelchair. The resident tripped and hit his/her head on the wheelchair. No injury was noted. The resident's Quarterly MDS Assessment of 1/18/16 indicated the resident required limited assistance of one for ambulation, was always incontinent of bowel and bladder, and had fallen with no injury. The resident's Quarterly MDS Assessment of 4/14/16 indicated the resident required extensive assistance of one for ambulation. Observation of the resident on 4/26/16 at 12:32 P.M. revealed the resident seated in the unit dining room with repetitive movement. At 12:45 P.M., the resident ambulated with staff to the Activity Room, singing as the resident walked. During interview on 4/27/16 at 9:15 A.M., the resident's assigned daytime Certified Nursing Assistant (CNA) #1 said that usually the night time staff got the resident up for breakfast, that the resident was incontinent of bowel and bladder, required one person assistance for all Activities of Daily Living, sang continuously throughout the day, and had no history of falls that she could remember. During interview on 4/27/16 at 2:00 P.M., Unit Manager #1 said that the facility had not provided the resident with non-skid socks, a bed alarm, and close supervision to prevent repeated falls with injury. Observation on 5/4/16 at 8:00 A.M. revealed the resident asleep in bed prior to morning care. There was no impact mat to either side of the resident's bed as planned. At 10:15 A.M., the resident was observed in bed after the breakfast meals, asleep. There was no impact mat next to the resident's bed as planned. Upon Surveyor inquiry, the unit's Program Manager entered the resident's room and said there was no impact mat next to the resident's bed. She said it looked like staff had put the impact mat next to the resident's roommate's bed. 2. For Resident #8, the facility failed to provide adequate assistance to prevent 4 falls, in which one fall resulted in a fractured hip and another fall resulted in a laceration. Resident #8 was admitted to the Facility in 3/2012 with [DIAGNOSES REDACTED]. Review of the falls care plan, dated 1/10/14, indicated: - Independent with ambulation with a wheeled walker - Remind the resident to call for assist and keep the walker beside his/her bed. - Provide verbal cues for safety and sequencing as needed. - When resident is in bed, place all necessary items within reach. Review of the Quarterly MDS Assessment, dated 9/11/15, indicated that the resident was moderately impaired cognitively, required supervision for transfers and ambulation and had no falls since the previous MDS assessment. Review of the Nurse's Note, dated 11/23/15, indicated that at 4:30 P.M. the resident sustained [REDACTED]. The nurse's note also indicated that there was a glass of spilled milk on the floor. The resident further stated, I spilt the milk after I fell . Further review of the incident indicated that the resident was not using his/her walker as care planned and sustained a left proximal femoral fracture. (fractured hip). Review of the falls care plan indicated no new interventions. Review of the Annual MDS Assessment, dated 12/4/15, indicated that the resident was moderately cognitively impaired, required extensive assistance with transfers and ambulation and had no falls since the prior assessment. Review of the nurse's note, dated 1/2/16, indicated that at 3:30 P.M., the resident sustained [REDACTED]. Further review indicated that the resident was sent to the emergency room and received sutures to close the laceration. Record review indicated the resident was in his/her wheelchair, dropped an item and over extended his/her reach. Review of the falls care plan indicated that on 1/4/16, the care plan was updated to include the following interventions: - Alarming floor mat to left side of bed. - Bed in low position. - Encourage to participate in activity group in supervised area when out of bed. - Ensure that a reacher/grabber is within reach at all times when the resident is in his/her room. Review of the nurse's note, dated 2/12/16, indicated that at 3:45 P.M. the resident's chair alarm sounded and the resident was found on the floor. The resident did not sustain an injury. Further review indicated that the fall was witnessed, in the dayroom. A CNA observed the resident stand up to pick up a piece of chocolate that the resident had dropped on the floor. The resident fell before the CNA could get to him/her to prevent the fall. Review of the falls care plan indicated that on 2/17/16 the falls care plan was updated to include: - Chair alarm to alert staff of the resident's need to ambulate. Review of the care plan indicated that the following intervention was added to the Activities of Daily Living care plan on 2/17/16: - Resident ambulates with contact guard assist, uses a wheeled walker. Review of the quarterly MDS Assessment, dated 2/26/16, indicated that the resident was moderately cognitively impaired, required extensive assistance with transfers and ambulation and had 1 fall with no injury and 1 fall with injury (except major) since the last MDS assessment. Review of the nurse's note, dated 3/27/16, indicated that at 9:30 P.M. the resident sustained [REDACTED]. The resident sustained [REDACTED]. Further review indicated that the alarm sounded, the bed was in the low position, and the mat was in place. Review of the falls care plan indicated that no new interventions were put into place. The surveyor observed Resident #8 on 5/3/16 at 1:45 P.M., The resident was in the activity room, an alarm on the chair and the walker beside the chair. During an interview with Unit Manager (UM) #2 on 5/4/16 at 8:45 A.M., she said that the resident was supposed to utilize a walker ( as per Falls Care Plan) and should not have been carrying milk while walking. UM #2 further stated that there were no new interventions put into place after the first fall. 3. For Resident #18 the facility failed to provide adequate footwear, assistance and supervision to prevent falls. The resident sustained [REDACTED]. All four falls occurred between the hours of 6:45 P.M. and 7:45 P.M. Resident #18 was admitted to the facility in 1/2009 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 4/16/14, indicated: - Requires assistance of 1 staff with the walker. - Slipper socks when not wearing shoes and out of bed. - Utilize low bed. - Monitor for and assist with toileting needs. Review of the quarterly MDS assessment, dated 4/3/15, indicated that the resident was severely cognitively impaired, required extensive assistance with transfers and ambulation and had no falls since the last MDS Assessment. Review of the nurse's note,dated 6/13/15, indicated that at 7:30 P.M., the resident was ambulating with a CNA, picked up a caution sign and fell . Further review of the incident indicated that water was leaking in the bathroom. Review of the falls care plan indicated that on 6/13/15, the care plan was updated to include the following intervention: - Replace floor caution sign with wall caution sign. Review of the quarterly MDS assessment, dated 6/29/15, indicated that the resident was severely cognitively impaired, required extensive assistance with transfers and ambulation and had 1 fall with no injury since the last MDS Assessment. Review of the nurse's note, dated 7/31/15, indicated that at 7:35 P.M. the resident sustained [REDACTED]. Further review indicated that the resident received an abrasion to his/her left lateral forearm. The resident was not assisted with ambulation as care planned. Review of the falls care plan indicated no new interventions. Review of the annual MDS assessment, dated 9/25/15, indicated that the resident was severely cognitively impaired, required extensive assistance with transfers and ambulation and had 1 fall with injury (except major) since the last MDS Assessment. Review of the nurse's note, dated 9/28/15, indicated that at 6:45 P.M. the resident sustained [REDACTED]. Further review indicated that the CNA in the supervised area was assisting another resident and did not observe the resident fall. The resident sustained [REDACTED]. Review of the care plan indicated that on 9/29/15, the care plan was updated to include the following intervention: - Therapy screen. Review of the quarterly MDS assessment, dated 12/23/15, indicated that the resident was severely cognitively impaired, required extensive assistance with transfers and ambulation and had 1 fall with injury (except major) since the last MDS Assessment. Review of the nurse's note, dated 12/25/15, indicated that at 7:45 P.M. the resident started to fall and was lowered to the floor. Further review indicated that the bottom of the resident's shoes were smooth and free of tread. Review of the falls care plan indicated that on 12/25/15, the care plan was updated to include the following interventions: - Ensure the resident has proper fitting footwear when out of bed. - Ensure the resident is a one assist when ambulating. The surveyor observed Resident #18 on 5/4/16 at 8:30 A.M. Resident #18 was seated in the dining room and had sneakers on his/her feet. During an interview with Unit Manager #1 on 5/4/16 at 9:30 A.M., she said that the resident should be in a supervised area and have his/her walker within reach. The resident required assistance with ambulation. The resident also should not have worn shoes that were smooth and threadbare. 4. During Environmental tours on 5/4/16, from 7:30 A.M. to 8:40 A.M., and from 9:00 A.M. to 9:30 A.M. with the Administrator, Director of Nursing and Maintenance Supervisor, the following were observed: 1. Transitional Care Unit: On the bathroom sink for Room A10 were an 8 fluid (fl.) ounce (oz.) opened plastic container of Heydreth cleanser, and an 8 fl. oz. opened plastic container of shampoo and body wash. Both had the warning For External Use Only. On the bathroom shelf for Room A11 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom hand rail for Room A18 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom hand rail for Room A21 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room B30 were a 8 fl. oz. opened plastic container of moisturizing cream, and an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room B31 was a 4 fl. oz. opened plastic container of moisturizing cream. On the bathroom sink for Room C43 was a 4 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room C44 were an 8 fl. oz. opened plastic container of Heydreth cleanser, an 8 fl. oz. opened plastic container of shampoo and body wash, and a 4 fl. oz. plastic container of mouthwash with the warning to Keep out of Eyes. Leeds Unit: On the bathroom hand rail for Room 107 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room 112 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room 114 was an 8 fl. oz. opened plastic container of shampoo and body wash. On the bathroom sink for Room 120 were two 8 fl. oz. opened plastic containers of shampoo and body wash. On the bathroom hand rail for Room 124 was an 8 fl. oz. opened plastic container of shampoo and body wash. Long Term Care Unit: On the bathroom toilet top for Room 201 was an 8 fl. oz. opened plastic container of Heydreth cleanser. On the bathroom hand rail for Room 207 were an 8 fluid (fl.) ounce (oz.) opened plastic container of moisturizer and an 8 fl. oz. opened plastic container of shampoo and body wash. In the plastic basin on the over the bed table next to Bed 1 in Room 218 was an 8 fl. oz. opened plastic moisturizing cream. On the over the bed table next to Bed 2 in Room 223 was a 4 fl. oz. opened plastic container of Nutrashield moisturizer with the warning For External Use Only. On the bathroom hand rail for Room 207 was an 8 fl. oz. opened plastic container of moisturizer and on the sink was an 8 fl. oz. opened plastic container of shampoo and body wash. On the sink for Room 227 was an 8 fl. oz. opened plastic container of shampoo and body wash. During the Observations there was no personal care being provided which would have accounted the open containers in the bathrooms. During observation of the chemical hazards and interviews with the Administrator and the Director of Nursing on 5/4/16 at 9:30 A.M., both said the above items would be immediately secured.

Based on record review, observations and staff interviews, the facility failed to follow the resident's written plan of care for 3 of 24 sampled residents (#4, #8 and #18). Findings include: 1. For Resident #4, the facility did not provide supervision, a bed alarm, proper non-skid socks and an impact mat to prevent 3 falls which resulted in injury (a fractured shoulder, radius and ulna and laceration with sutures), from 3/19/15 to present. Resident #4 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. A care plan to have no falls due to risk for falls, cognitive loss and lack safety awareness, dated 3/18/15, had the following interventions: -Resident is able to ambulate short distances, needs direction and cueing related to impaired vision, -and Resident to wear non-skid socks while in bed and shoes when out of bed, Record review of 3/19/15 at 10:15 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident had an unwitnessed fall when found laying on the floor on the left side and crying reporting left arm pain. The resident was sent to the local hospital and found to have an acute [MEDICAL CONDITION] shoulder, left radius and ulna. It was noted that the resident had bare feet and not the non-skid socks as planned when the resident was in bed. It was recommended that the care plan be updated to include: -Ambulate with the resident with one assist, -and Have a bed alarm while in bed. Record review of 6/16/15 at 8:50 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident was observed by staff naked and walking in the hallway. The Resident was previously observed in bed. The resident was escorted by staff to his/her bedroom. As the resident and staff walked into the room, the resident slid and fell to the floor. There was urine on the floor and staff did not see the pool of urine. The resident sustained [REDACTED]. The resident was sent to the local hospital and received 5 sutures to the forehead. The investigation indicated the resident did not have on non-skid socks at the time. The reports do not indicate if the bed alarm was in place, as planned, and sounding The care plan for falls was updated 7/26/15 to include an impact mat to the right side of the resident's bed. Record review of 11/9/15 at 5:45 P.M. Progress Notes, Risk Management System Notes and Incident Report indicated the resident was observed by staff walking in the hallway without staff assistance (as planned) into another resident's wheelchair. The resident tripped and hit his/her head on the wheelchair. No injury was noted. Observation of the resident on 4/26/16 at 12:32 P.M. revealed the resident seated in the unit dining room with repetitive movement. At 12:45 P.M., the resident ambulated with staff to the Activity Room, singing as the resident walked. During interview on 4/27/16 at 9:15 A.M., the resident's assigned daytime Certified Nursing Assistant (CNA) #1 said that usually the night time staff got the resident up for breakfast, that the resident was incontinent of bowel and bladder, required one person assistance for all Activities of Daily Living, sang continuously throughout the day, and had no history of falls that she could remember. During interview on 4/27/16 at 2:00 P.M., Unit Manager #1 said that the facility had not provided the resident with non-skid socks, a bed alarm, and close supervision to prevent repeated falls with injury. Observation on 5/4/16 at 8:00 A.M. revealed the resident asleep in bed prior to morning care. There was no impact mat to either side of the resident's bed as planned. At 10:15 A.M., the resident was observed in bed after the breakfast meals, asleep. There was no impact mat next to the resident's bed as planned. Upon Surveyor inquiry, the unit's Program Manager entered the resident's room and said there was no impact mat next to the resident's bed. She said it looked like staff had put the impact mat next to the resident's roommate's bed. 2. For Resident #8 the facility failed to ensure the resident utilized his/her walker as care planned. Resident #8 was admitted to the Facility in 3/2012 with [DIAGNOSES REDACTED]. Review of the falls care plan, dated 1/10/14, indicated: - Independent with ambulation with a wheeled walker - Remind the resident to call for assist and keep the walker beside his/her bed. - Provide verbal cues for safety and sequencing as needed. - and When resident is in bed, place all necessary items within reach. Review of the Nurse's Note, dated 11/23/15, indicated that, at 4:30 P.M., the resident sustained [REDACTED]. The nurse's note also indicated that there was a glass of spilled milk on the floor. The resident further stated, I spilt the milk after I fell . Further review of the incident indicated that the resident was not using his/her walker as care planned and sustained a left proximal femoral fracture. ([MEDICAL CONDITION]). The surveyor observed Resident #8 on 5/3/16 at 1:45 P.M., The resident was in the activity room, an alarm on the chair and the walker beside the chair. During an interview with Unit Manager (UM) #2 on 5/4/16 at 8:45 A.M., she said that the resident did not use the walker as care planned. 3. For Resident #18, the facility failed to follow the plan of care regarding adequate footwear and assistance with ambulation. Resident #18 was admitted to the facility in 1/2009 with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 4/16/14, indicated: - Requires assistance of 1 staff with the walker. - Slipper socks when not wearing shoes and out of bed. - Monitor for and assist with toileting needs. Review of the Nurse's Note, dated 7/31/15, indicated that at 7:35 P.M., the resident sustained [REDACTED]. Further review indicated that the resident received an abrasion to his/her left lateral forearm. The resident was not assisted with ambulation as care planned. Review of the Nurse's Note, dated 12/25/15, indicated that at 7:45 P.M., the resident started to fall and was lowered to the floor. Further review indicated that the bottom of the resident's shoes were smooth and free of tread. The resident was not wearing slipper socks or shoes as care planned. Review of the falls care plan indicated that on 12/25/15, the care plan was updated to include the following interventions: - Ensure the resident has proper fitting footwear when out of bed. - Ensure the resident is a one assist when ambulating. The surveyor observed Resident #18 on 5/4/16 at 8:30 A.M. Resident #18 was seated in the dining room and had sneakers on his/her feet. During an interview with Unit Manager #1 on 5/4/16 at 9:30 A.M., she said that the resident should be in a supervised area and have his/her walker within reach. The resident required assistance with ambulation, as care planned. The resident also should have worn either slipper socks or shoes with treads.