Every finding on record at Highland Park Rehabilitation and Healthcare Center

Based on record review, interview and observation, the facility failed to implement the contracted Pest Control Company's recommendations to make repairs for the control of mice and cockroaches on three of four resident floors. Findings include:Review of the Pest Control Company report dated 2/26/26 indicated it maintained bait traps and inspected the facility's physical environment for mice and cockroaches. The report indicated:room [ROOM NUMBER]. Condition, hole in wall located near floor. Baseboard split from wall. room [ROOM NUMBER]'s condition was identified by the Pest Control Company on 9/12/25.On 3/5/26 at 10:00 A.M., the surveyor observed that room [ROOM NUMBER] had holes in the bedroom walls and the baseboard had peeled away from the wall and exposed holes in the wall. The floor had areas of mice droppings.room [ROOM NUMBER]. Cluttered conditions - closet is cluttered. Mice are nesting. room [ROOM NUMBER]'s condition was identified by the Pest Control Company on 10/22/25.On 3/5/26 at 10:07 A.M., the surveyor observed that the bathroom shared by rooms [ROOM NUMBERS] had several holes measuring 1 to 4 in diameter. The floor had areas of mice droppings.room [ROOM NUMBER]. Hole in the wall located near floor need to be patched. Several holes in bathroom. Active mice activity in room. room [ROOM NUMBER]'s condition was identified by the Pest Control Company on 2/12/26.On 3/5/26 at 10:15 A.M., the surveyor observed a hole in room [ROOM NUMBER]'s wall, which measured approximately 1 in diameter. The bathroom walls had several holes which measured 1 to 2 in diameter. The floor had areas of mice droppings.On 3/5/26 at 11:30 A.M. the Maintenance Director, accompanied the surveyor, observed holes in the walls in rooms 408, 515 and 618. The Maintenance Director said he was unaware the Pest Control Company recommended that these holes be patched to prevent the entry of mice and roaches.During the resident group meeting held on 3/4/26 at 11:11 A.M., several residents said that for approximately the past six months mice and cockroaches have infested their bedrooms.During an interview with the Administrator on 3/5/26 at 11:56 A.M., the surveyor described the condition of rooms 408, 515 and 618. The Administrator said she was aware of the Pest Control Company's repair recommendations and that the facility had a mice and cockroach problem. The Administrator said the facility was doing its best to eradicate the pests.

Based on observation and interview, the facility failed to maintain a sanitary and comfortable environment on three of four resident floors. Specifically, the facility failed to:Maintain and replace stained and bowed ceiling tiles in resident hallways on the third, fourth and fifth floors.Patch holes in walls in resident bedrooms.Findings include:On 3/5/26 at 10:00 A.M., the surveyor observed resident floors three, four and five. Each of the identified ceiling tiles listed below had circular brown stains measuring at least 10 inches in diameter.Third floor:Hallway in front of room [ROOM NUMBER] four stained and bowed tiles.Hallway in front of room [ROOM NUMBER] two stained tiles.Hallway in front of room [ROOM NUMBER] five stained and bowed tiles. Fourth floor:Hallway in front of room [ROOM NUMBER] two stained tiles.Hallway in front of room [ROOM NUMBER] two stained tiles.room [ROOM NUMBER] 1/2 x 10 gap between back of toilet and wall. room [ROOM NUMBER] 1 diameter hole in bedroom wall. Several 1 holes in bathroom walls Hallway in front of room [ROOM NUMBER] two stained ceiling tiles.Hallway in front of room [ROOM NUMBER] two stained and bowed tiles.Hallway in front of exit door located between rooms [ROOM NUMBERS] two stained tiles.Hallway in front of room [ROOM NUMBER] two stained ceiling tiles. Fifth floor:room [ROOM NUMBER] 1 diameter hole at the bottom of the wall next to entry door. Hallway in front of the activity room three stained ceiling tiles.Ceiling tiles next to air vent located in front of the nursing station are stained black.room [ROOM NUMBER] and 517 common bathroom peeled baseboard with two holes in the wallsHallway in front of room [ROOM NUMBER] two stained ceiling tiles On 3/5/26 at 11:30 A.M. the surveyor and the Maintenance Director toured the third, fourth and fifth resident floors. The Maintenance Director observed the stained hallway ceiling tiles and the holes in the walls in rooms [ROOM NUMBERS] and in the common bathroom for rooms [ROOM NUMBERS]. The Maintenance Director said he was aware of the stained ceiling tiles and had been able to replace two or three in the past month, but that the building did not have any more tiles in the building. The Maintenance Director said he had been working in the building for less than a month and had not been made aware of the holes in the walls in residents' bedrooms. During an interview with the Administrator on 3/5/26 at 11:56 A.M., the surveyor described the conditions of the ceiling tiles on the third, fourth and fifth floors and the holes in the walls in rooms 408, 504, 515 and 517. The Administrator said she was aware of the physical condition of the residents' floors and staff were doing their best to maintain the building. The Administrator said there are plans to renovate the building and that walls and ceiling tiles would be repaired.

Based on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding Included:Review of the facility policy titled Minimum Staffing-Massachusetts, undated, indicated the following:-On or after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day of 3.580 hours, of which at least 0.508 hours must be care provided to each resident by a registered nurse.-The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD. Review of the facility assessment indicated the following: Staffing Guidelines -Our facility has created a base staffing pattern to ensure a sufficient number of qualified staff to meet the needs of our residents on a consistent basis. Our staffing pattern is further developed based on the assessed nursing care needs of our residents, acuity, and census. The base staffing pattern represents typical staffing based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors including but not limited to, shifts in resident census, acuity, communicable disease outbreak, and admission or discharge volume. Revisions to staffing based upon currently identified resident needs may be reflected in an increase or decrease in staffing from what is noted in the base staffing pattern.-Staffing assignments are determined by looking at both census and acuity of the residents. We look at both admission and discharge volume to ensure that residents' needs are met. The staffing pattern fluctuates when it is determined that one unit or shift needs additional assistance. All efforts are made to promote consistent assignments. Our staffing process includes ensuring that resident needs are met in the face of challenges related to call outs or emergent situations.- In the event of staffing challenges, our facility may utilize contracted staff to ensure that the needs of the residents are met. Contracted staff would be provided with appropriate education to ensure knowledge of the facility systems and processes. The Administrator provided the surveyor with the hours per patient per day (HPPD) report that indicated the staffing levels for the building. The report indicated the following: -The budgeted hours per patient per day (HPPD) for the facility census is 3.5 and indicated for the months of November, December, January and February the facility failed to meet the appropriate staffing levels for 120 of 120 days. During an interview on 3/5/26 at 12:00 P.M., the Corporate Administrator said she would expect the minimum staffing levels to be maintained but it has been challenging, and we have been utilizing agency to help with our staffing levels.

Based on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards of practice for five Residents (#182, #7, #127, #20 and #90) out of 37 total sampled residents. Specifically,1. For Resident #182, the facility failed to complete liver function tests and a basic metabolic panel as ordered.2. For Resident #7 the facility failed to ensure weekly skin checks were completed.3. For Resident #127 the facility failed to ensure weekly skin checks were completed.4. For Resident #20 the facility failed to ensure weekly skin checks were completed as indicated in physician's orders.5. For Resident #90 the facility failed to implement a physician treatment order for a cheek wound.Findings include:1. Resident #182 was admitted to the facility in August 2023 with diagnoses including cerebral infarction. Review of the most recent Minimum Data Set (MDS), dated [DATE], did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely or never understood. Review of Resident #182's March 2026 physician's orders indicated the following: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 Milligrams (Divalproex Sodium), give 4 capsules by mouth three times a day for seizure disorder. Start date 8/11/25. -Valproic acid, BMP (Basic Metabolic Panel) and LFT (Liver Function Tests) every 6 months (February and August) every night shift every 6 month(s) starting on the 1st for 7 day(s) related to hyperlipidemia, 11-7 please complete lab (laboratory) slip and flag for A.M. (morning) draw. Start date 2/1/26. Review of the February and March 2026 Medication Administration Record (MAR) indicated that staff administered Depakote Sprinkles as ordered. Further review of Resident #182's medical record failed to indicate that a BMP and LFT was completed as ordered. During an interview and medical record review on 3/4/26 at 9:16 A.M., Unit Manager #2 reviewed the medical record and said that the LFT and BMP were not completed as ordered. Unit Manager #2 said physician's orders should be followed. During an interview and medical record review on 3/4/26 at 9:57 A.M., the Nurse Practitioner reviewed the medical record and said the February labs had not been completed. The Nurse Practitioner said physician's orders should be followed and Resident refusals should be documented. The Nurse Practitioner said if the Resident refuses labs, the Nurses should notify her and document that information. The Nurse Practitioner said staff have not notified her that the Resident has refused labs. During an interview on 3/4/26 at 12:44 P.M., the Director of Nurses and the Regional Nurse Consultant said that physician's orders should be followed, and the Resident's labs should have been completed as ordered. 2. Resident #7 was admitted to the facility in February 2020 with diagnosis that included type two diabetes mellitus, vitamin deficiency, repeated falls and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Review of Resident #7's skin care plan indicated the following: I have skin breakdown and/or potential for skin breakdown r/t (related to) decreased mobility and DM (diabetes mellitus). Date Initiated: 4/11/25.Interventions included: Document skin checks weekly and PRN (as needed). Notify the physician and resident/RP (resident representative) of new areas if observed. Follow-up as indicated. I need reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Notify nurse immediately of any skin changes: redness, blisters, bruises, discoloration, etc. noted. Review of the Norton Assessment (an assessment to determine a resident's risk for skin breakdown and the development of pressure ulcers), completed 12/29/25, indicated a risk score of 12; indicating high risk for skin breakdown. Review of Resident #7's active physician orders indicated the following:-Weekly Skin Check Monday 3P.M. -11P.M. every evening shift every Mon (Monday). Complete in PCC (Point Click Care/Electronic Medical Record). Start Date 6/30/25. Review of the Electronic Medical Record (EMAR) indicated the last documented weekly skin check was completed on 2/16/26. Review of the Treatment Administration Record (TAR) for the months of February 2026 and March 2026 indicated the following:-Weekly Skin check dated 2/23/26 was checked off on the TAR as completed but failed to document the weekly skin assessment.-Weekly Skin check dated 3/2/26 was checked off on the TAR as completed but failed to document the weekly skin assessment. During an interview on 3/5/26 at 10:04 A.M., Nurse #7 said weekly skin checks must be documented under weekly skin assessments and not just checked off as completed on the TAR. Nurse #7 and the surveyor reviewed the medical record and Nurse #7 said the last documented skin check was on 2/16/26 and was not completed on 2/23/26 or 3/2/26. During an interview on 3/5/26 at 10:11 A.M., Unit Manager #3 said Resident #7 is missing documented skin assessments on 2/23/26 and 3/2/26 and said the skin checks should have been completed as ordered. Unit Manager #3 said some staff do not know they need to check off the order on the treatment record but must also complete the skin assessment to document the skin check. During an interview on 3/5/26 at 1:02 P.M., the Director of Nursing said weekly skin assessments must be documented and completed as ordered and not checked off as completed in the treatment record when they were not done. 3. Resident #127 was admitted to the facility in July 2025 with diagnoses that included malignant neoplasm of the brain, muscle weakness and history of falling. Review of the Minimum Data Set (MDS) assessment, dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Review of Resident #127's active care plan indicated the following: -I have skin breakdown and/or potential for skin breakdown r/t (related to) incontinence with interventions that included to document skin checks weekly and PRN. Notify the physician and resident of new areas if observed. Follow-up as indicated, dated as revised 10/27/25. Review of Resident #127's most recent Norton Assessment, dated 12/29/25, indicated a risk score of 7 which indicated that the Resident is at high risk for skin breakdown. Review of Resident #127's medical record since 12/1/25 indicated skin checks were completed on the following dates: 12/6/25, 12/13/25, 1/18/26. 1/25/26, 1/25/26, 2/1/26, 2/5/26 and 2/15/26. Resident #127's medical record indicated that weekly skin checks were completed 8 out of 13 weeks during the time period reviewed. During an interview on 3/5/26 at 8:49 A.M., Nurse #7 said that skin checks are completed weekly on all residents. She said competing the skin check includes completing the assessment in the electronic medical record. During an interview on 3/5/26 at 12:20 P.M., Unit Manager #3 said that the staff nurses complete skin checks weekly. She said they must enter the assessment into the assessment in the electronic medical record. During an interview on 3/5/26 at 1:10 P.M., the Director of Nurses said that skin checks are completed weekly on all residents. She said if a Resident refuses a skin check it should be documented in the medical record. She said that signing off completion of the skin check on the Treatment Administration Record does not indicate the skin check is completed, the nurses must also complete the assessment in the electronic medical record. 4. Resident #20 was admitted to the facility in August 2024 with diagnoses that included major depressive disorder and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 2/12/26, indicated a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident is dependent for bed mobility Review of the Residents active care plan indicated the following: -I have potential for skin breakdown r/t (related to) bowel and bladder incontinence, dated 5/30/25 with an intervention that included to document skin checks weekly and PRN. Notify the physician and resident of new areas if observed. Follow-up as indicated. Review of Resident #20's most recent Norton Assessment (a tool to determine a resident's risk for skin breakdown and pressure ulcer development), dated 2/9/26, indicated a score of 6, indicating that the Resident is at high risk for skin breakdown. Review of Resident #20's physician's orders indicated the following: -Weekly skin check Friday 3-11, every evening shift for Weekly Skin Monitoring complete weekly skin check in [electronic medical record], dated 7/4/25. Review of the medical record indicated that skin checks were not completed as indicated in physician's orders on 12/17/25, 12/24/25, 1/7/26, 2/25/26 or 3/4/26 During an interview on 3/5/26 at 8:49 A.M., Nurse #7 said that skin checks were completed weekly on all residents. She said competing the skin check includes completing the assessment in the electronic medical record. During an interview on 3/5/26 at 12:20 P.M., Unit Manager #3 said that the staff nurses complete skin checks weekly. She said they must enter the assessment into the assessment in the electronic medical record. During an interview on 3/5/26 at 1:10 P.M., the Director of Nurses said that skin checks were completed weekly on all residents. She said if a Resident refused a skin check it should be documented in the medical record. She said that signing off completion of the skin check on the Treatment Administration Record did not indicate the skin check is completed, the nurses must also complete the assessment in the electronic medical record. 5. For Resident #90 the facility failed to implement a physician treatment order for a cheek wound. Review of the facility policy titled Wound Care, revised October 2010, indicated, but was not limited to, the following: Preparation: 1. Verify that there is a physician's order for this procedure. The following information should be recorded in the residents' medical record: The type of wound care given. The date and time the wound care was given. The position in which the resident was placed. The name and title of the individual performing the wound care. Any change in the resident's condition All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. How the resident tolerated the procedure. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment and the reason(s) why. The signature and title of the person recording the data. Resident #90 was admitted to the facility in June 2020 with a diagnosis of Alzheimer's disease. Review of the MDS, dated [DATE], indicated that Resident #90 was not able to complete a Brief Interview for Mental Status (BIMS) as the Resident was rarely/never understood. Review of Resident #90's active care plans indicated the Resident had potential for skin breakdown. Review of Resident #90's hospice services communication note, dated 2/11/26, indicated the Resident had a chronic scab on his/her right cheek which was getting larger and that the hospice nurse notified the hospice wound nurse. Review of Resident #90's hospice services communication note, dated 2/12/26, indicated the following: Wound rec per hospice wound nurse: cover chronic right cheek wound with 2x2 dry protective dressing to prevent picking; may apply A&D ointment. Review of Resident #90's active physician orders indicated the following order: Wash right check with wound cleanser, pat dry and cover with DPD (2x2) may apply A&D ointment daily and when needed to prevent picking (sic.), initiated 2/13/26. Further review of the orders scheduling details indicated a frequency of at least once per day shift between the hours of 7 A.M. and 3 P.M. On 3/3/26 at 9:38 A.M. the surveyor observed Resident #90 in his/her bed, the Resident had a wound on his/her right cheek; there was no dressing on the wound. Resident #90 was not able to participate in an interview. On 3/3/26 at 12:55 P.M. the surveyor observed Resident #90 in his/her bed, the Resident had a wound on his/her right cheek; there was no dressing on the wound. There was staff in the Residents room providing assistance to the Resident. On 3/3/26 at 4:15 P.M. the surveyor observed Resident #90 in his/her bed, the Resident had a wound on his/her right cheek; there was no dressing on the wound. On 3/4/26 at 7:51 A.M. the surveyor observed Resident #90 in his/her bed, the Resident had a wound on his/her right cheek and there was dried blood present on and around the perimeter of the wound; there was no dressing on the wound. There was staff in the Residents room providing assistance to the Resident. On 3/4/26 at 10:27 A.M. the surveyor observed Nurse #1 administer medication to Resident #90 who had a wound on his/her right cheek which had dried blood present on and around the perimeter of the wound; there was no dressing on the wound. The nurse did not attempt or offer to provide Resident #90's wound care treatment. On 3/4/26 at 11:46 A.M., 12:51 P.M., 1:31P.M., 2:11 P.M., 2:48 P.M., 3:23 P.M., and 3:57 P.M. the surveyor observed Resident #90 in his/her bed, the Resident had a wound on his/her right cheek and there was dried blood present on and around the perimeter of the wound; there was no dressing on the wound. Review of Resident #90's Medication/Treatment Administration Record (MAR/TAR) on 3/4/26 at 3:57 P.M. indicated that Nurse #1 had not yet completed the Residents right cheek wound treatment. On 3/4/26 from 3:57 P.M. to 4:05 P.M. during a continuous observation the surveyor observed that Nurse #1 had not implemented or attempted to implement Resident #90's right cheek wound treatment. Resident #90 was in his/her bed, the Resident had a wound on his/her right cheek and there was dried blood present on and around the perimeter of the wound; there was no dressing on the wound. Review of Resident #90's Medication/Treatment Administration Record on 3/4/26 at 4:05 P.M. indicated Nurse #1 had documented that she had completed Resident #90s right cheek wound treatment. Review of Resident #90's electronic and physical medical record failed to indicate documentation regarding any issues, refusals, reapplication or attempts in implementing Resident #90s wound treatment on 3/3/26 or 3/4/26. During an interview on 3/4/26 at 4:18 P.M. Nurse #1 said she would expect a physician's order for a wound treatment to be implemented and that if the Resident refused this would be documented. Nurse #1 said Resident #90's right cheek wound should be cleaned with a wound cleanser, dried, ointment applied and then covered with 2x2 dry protective dressing as the Resident tended to pick at the right cheek wound. Nurse #1 said the order should read cheek not check as this was a typo. Nurse #1 said Resident #90 typically did not refuse treatment and had not refused his/her wound care treatment that day. Nurse #1 said Resident #90's right cheek wound treatment should have been completed during the 7-3 shift but that she had not completed it or attempted to complete it. Nurse #1 said she should not have marked the treatment order as completed on the MAR/TAR as she had not completed it. During an interview on 3/5/26 at 10:07 A.M. Nurse #10 said that Resident #90 had a wound/cancerous lesion on his/her cheek and that if the wound was dry and not draining that nurses would not cover it with dry protective dressing. Nurse #10 said she had applied the dry protective dressing on 3/4/26 but that the dressing came off and she had not reapplied it. During an interview on 3/5/26 at 9:51 A.M. Unit Manager #2 said she would expect a physician order for a wound treatment to be implemented. The Unit Manager said there should be a nursing note if the nurse was unable to implement the treatment order and that she would expect a nurse to reapply the dry protective dressing to Resident #90's cheek if it had come off. Unit Manager #2 said that Resident #90's dry protective dressing was in place to keep the Resident from scratching at the wound, which the Resident tended to do, as this would put the wound at risk for opening and becoming infected. During an interview on 3/5/26 at 11:19 A.M. the Director of Nursing (DON) said that she would expect a physician order for wound treatment to be implemented, and that if Resident #90's dry protective dressing had come off she would expect the nurse to reapply the dressing; the DON said the order should say cheek not check. The DON said that if the nurse was unable to reapply the dry protective dressing that this would be documented and reported to the Nurse Practitioner. The DON said that when an outside service makes a recommendation and it is reviewed by the physician, and even if the physician changes what was recommended, that staff should go by what the physician ordered.

Based on observation, record review and interview, the facility failed to accommodate the needs of one Resident (#20) out of a total of 37 sampled residents. Specifically, the facility failed to provide a wheelchair or other seating able to fit Resident #20, resulting in Resident #20 being unable to get out of bed.Findings include:Resident #20 was admitted to the facility in August 2024 with diagnoses that included major depressive disorder and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 2/12/26, indicated a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS further indicated a diagnosis of depression is present. Further review of the MDS indicated that the Resident was Dependent for bed mobility and transfers. On 3/3/26 at 8:36 A.M., the surveyor observed Resident #20 awake and in bed. The Resident was weepy and said that he/she does not get out of bed because there was not a wheelchair large enough to accommodate him/her. There was a wheelchair in the corner of the Resident's room that was small and piled with many briefs, blankets and other supplies. The Resident said that they hadn't been able to sit in that chair for some time now. On 3/3/26 at 1:13 P.M., the surveyor observed Resident #20 in bed. He/she said they had not gotten out of bed today and were not offered by staff to get out of bed. On 3/4/26 at 9:00 A.M., the surveyor observed Resident #20 in bed. The Resident said that he/she had not gotten up out of bed in a few months because of not having a wheelchair to accommodate him/her. The Resident said that he/she had recently gained a lot of weight and could no longer utilize the wheelchair in his/her room. He/she said that they cannot attend activities or socialize because they are unable to get out of bed due to lack of seating. Resident #20 said, I feel like I am just stuck here and can't get up. On 3/5/26 at 8:38 A.M. and 11:43 A.M., the Resident was observed awake in bed. Review of the Psychiatric Evaluation and Consultation note, dated 2/9/26 indicated the following:-Resident is alert and oriented and was observed lying in bed. Mood appeared irritable, tearful, and sad. He/she reports significant frustration with his/her functional limitations, stating, I am 63 y/o (years old) and I am not able to get out of bed and walk. Concentration is poor, though he/she expressed some interest in socialization. -Resident presents with emotional distress related to functional decline and loss of independence. Review of the medical record failed to indicate that Resident #20 was assessed and provided an appropriate seating accommodation to enable him/her to get out of bed. Further review of the medical record failed to indicate that the Resident was offered and refused opportunities to get out of bed. Review of Resident care plan indicated the following:I experience social isolation related to being bed bound and choosing to not get OOB (out of bed), updated 8/25/25.-Interventions included: Facilitate one on one interactions with others with similar interests and desires for social interaction. -Invite [Resident] to group activities and assist with attending as needed. Review of the activities of daily living (ADL) care plan, dated 5/30/25 indicated the following:I have an ADL Self Care Performance Deficit r/t (related to) Rheumatoid arthritis, lymphedema with venous insufficiency, generalized chronic pain with muscle weakness and immobility.Interventions included: AMBULATION: I am non-ambulatory. I use a manual wheelchair. Mobility Device: I use a manual wheelchair. During an interview on 3/4/26 at 11:14 A.M., Certified Nurse Aide (CNA) #2 said that she has been taking care of Resident #20 for about three months. She said that the Resident does not have a wheelchair or stationary chair available to him/her that they fit in and are able to get up to. She said that at this time if the Resident wanted to get out of bed, he/she would not be able to. During an interview on 3/4/26 at 11:21 A.M. the Regional Director of Rehab said that if a resident required a specialty wheelchair of any kind, then therapy would be the one to provide it. She said she did not recall a referral to see Resident #20 for appropriate seating. She said ideally every resident should have a chair as a means to get up and out of bed if they desire. She said she would expect nursing to make a referral for seating if they had no way of getting out of bed. During a follow up interview on 3/4/26 at 2:26 P.M., the Regional Director of Rehab said that she evaluated Resident #20 for seating, and the Resident was not able to utilize the chair in the Resident's room because it was too small. She said the Resident was in agreement with the facility ordering a chair to trial so that he/she can get up and out of bed. During an interview on 3/5/26 at 1:27 P.M., the Director of Nurses and Regional Nurse Consultant said that therapy should be doing routine screens and should notice and be aware of the fact that Resident #20 doesn't have an appropriate chair for when he/she wants to get out of bed. They further said that the Resident should have the opportunity to get up and have a wheelchair to accommodate him/her. She said that the Resident can't refuse if they don't have the appropriate accommodations. Review of documentation provided by the facility after survey exit on 3/6/26, indicated the facility had ordered a wheelchair on 2/23/26 for an unspecified resident. However, during the survey, staff were unable to locate the chair and Resident #20 remained in bed.

Based on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,The facility failed to ensure treatment carts were locked while a nurse was not present on two out of four unitsThe facility failed to ensure nursing staff stayed with the surveyors while doing the medication storage task on two out of four units.Findings include:Review of facility policy titled Medication Labeling and Storage, dated as revised February 2023, indicated the following:-The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 1. On 3/3/26 at 8:18 A.M., there was an unlocked and unattended treatment cart on the 6th floor unit. The surveyor was able to gain access to the cart which contained medicated creams and treatments. The cart was accessible to staff and residents in the area. On 3/4/26 at11:47 A.M., there was an unlocked and unattended treatment cart on the 4th floor unit. The surveyor was able to gain access to the cart which contained medicated creams and treatments. The cart was accessible to staff and residents in the area. During an interview on 3/4/26 at 1:58 P.M., the Director of Nurses said that all treatment carts should be locked when unattended. 2. On 3/4/26 at 1:04 P.M., the surveyor was left alone with an unlocked medication cart on the 4th floor unit while completing the medication storage task. The Nurse returned at 1:09 P.M. and then left the surveyor at the unlocked medication cart again to assist with passing meal trays. During an interview on 3/4/26 at 1:11 P.M., Nurse #8 said that he should not have left the surveyor alone with the medication cart.On 3/4/26 at 1:17 P.M., a staff nurse opened the medication room for the surveyor and left the surveyor unattended and unsupervised in the medication room during the medication storage task. When the surveyor exited the medication room at 1:20 P.M., the nurse who let the surveyor in the medication room was no longer outside of the room, and was unable to be located by the surveyor.During an interview on 3/4/26 at 1:58 P.M., with the Director of Nurses and Regional Nurse Consultant said that the surveyors should not have left the surveyor unsupervised but probably thought that they could because it was a surveyor.

Based on observation, record review and interview, the facility failed to ensure one Resident (#3) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 37 residents. Specifically, for Resident #3 the facility failed to implement recommendations from the Wound Doctor.Findings include:Resident #3 was admitted to the facility in October 2025 with diagnoses that included pressure ulcer of the sacral region, type 2 diabetes, hemiplegia and hemiparesis, and malignant neoplasm of lung. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/26, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS also indicated the Resident had one stage four and one stage three unhealed pressure ulcers. Review of Resident #3's impaired skin care plan, dated 10/9/25, indicated administer treatments as ordered and monitor effectiveness. Review of Resident #3's physician order, dated 1/12/26, indicated Pressure wound on Sacrum: Cleanse site with normal saline, apply Santyl (prescription ointment that breaks down collagen in damaged or dead skin), cover with superabsorbent gelling fiber with silicone faced border once daily. Review of Resident #3's Wound Physician recommendations, dated 2/19/26 and 2/26/26, indicated: apply to sacrum wound - calcium alginate apply once daily and as needed: if saturated, soiled, or dislodged. Superabsorbent gelling fiber w/ silicone border apply once daily and as needed: if saturated, soiled, or dislodged. Review of Resident #3's March 2026 Treatment Administration Record indicated that nursing staff were administering the following order to Resident #3's Sacrum: Cleanse site with Normal Saline, apply Santyl, cover with Superabsorbent Gelling Fiber with silicone faced border once daily. During an interview on 3/5/26 at 10:38 A.M., Nurse #6 said Resident #3 has chronic wounds and said the Wound Physician comes in weekly to assess the wounds. Nurse #6 said when the Wound Physician makes new recommendations that the new order should go in as soon as possible. During an interview on 3/5/26 at 11:39 A.M., the Director of Nursing (DON) said the wound doctor comes in weekly and tells the nursing staff of her new recommendations for each wound. The DON said then nursing will then update the physician order. During an interview on 3/5/26 at 12:33 P.M., the Wound Physician said that she rounds the facility weekly with nursing staff who then put in the treatment recommendations as orders. The Wound Physician said that she is in contact with the facility Nurse Practitioner and the Nurse Practitioner defers to her for treatments. The Wound Physician said she expects wound treatments be implemented timely. The Wound Physician was not aware the implementation of her recommendations were not in place for Resident #3.

Based on observation, record review and interview, the facility failed to provide a dignified existence for one Resident (#78) out of a total sample of 37 residents. Specifically, for Resident #78, the facility failed to remove unwanted facial hair.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated 4/25, indicated the following:-Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).-Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.-Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care)By the end of the survey the facility was unable to provide a policy on dignity.Resident #78 was admitted to the facility in August 2025 with diagnoses including gender identity disorder, dementia and depression. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #78 is severely cognitively impaired, scoring a 5 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #78 requires supervision to touching assistance with activities of daily living. Review of the CNA (Certified Nurse's Aide) personal hygiene daily documentation record dated 2/3/26 through 3/4/26 failed to indicate Resident #78 refused care. On 3/3/26 at 8:41 A.M., 12:17 P.M., and 1:28 P.M., the surveyor observed Resident #78 to have significant facial hair. During an interview on 3/3/26 at 8:41 A.M., Resident #78 said that he/she did not like the facial hair and found it embarrassing. Resident #78 then asked if there was any way to take it off and replied that would be great if it could be removed. On 3/4/26 at approximately 8:00 A.M., 9:00 A.M., and 10:45 A.M., the surveyor observed Resident #78 with significant facial hair. During an interview on 3/4/26 at approximately 10:45 A.M., Certified Nurse's Aide #4 said that she hasn't had time yet to care for Resident #78. During an interview on 3/4/26 at 12:00 P.M., Resident #78 said that the hair on his/her face is horrible. Resident #78 then said that no one had been in today, except for the surveyor, to offer to remove the facial hair. During an interview on 3/4/26 at 12:03 P.M., Nurse #3 said that she just interviewed Resident #78 and he/she wanted the facial hair removed. Nurse #3 then said that Resident #78's facial hair should have been removed with daily care.

Based on observation, record review and interview, the facility failed to promote resident rights to make choices about aspects of his/her life in the facility that are significant for one Resident (#134) out of a total of 37 sampled Residents. Specifically, the facility failed to allow Resident #134, an alert and oriented resident who is responsible for their own decision making, to leave the premises independently. Findings include:Review of the facility policy titled Resident Rights, undated, indicated:1. Federal and state laws guarantee certain basic rights to all residents of this facility.-These rights include the resident's right to:-a. a dignified existence-e. self-determination. Resident #134 was admitted to the facility in January 2025 in with diagnoses including paraplegia, post-traumatic stress disorder and major depressive disorder. Review of the Minimum Data Set assessment (MDS), dated [DATE], indicated he/she is cognitively intact as evidenced by a score of 13 out of possible 15 on the Brief Interview for Mental Status Exam. Additional review of the MDS indicated Resident #134 is dependent on staff for bathing and dressing. During an interview on 3/3/26 at 9:30 A.M., Resident #134 reported he/she has been upset that he/she was not allowed to go outside or off facility grounds independently. Resident #134 said the facility is like a prison and he/she can get around easily in his/her motorized scooter. Resident #134 said that staff have told him/her that he/she could not leave the premises without an escort. Review of Resident #134's clinical record indicated he/she did not have an activated health care proxy. Review of Resident #134's physicians orders indicated: Resident #134 may have supervised LOA (leave of absence) privileges at this time, initiated 11/24/25. Review of Resident #134's care plans indicated: Focus: I have a substance abuse disorder r/t (related to) opioid use. History of pocketing/hoarding pills when administered.Interventions: Facility to provide supervision/escort if resident has appointments or need to leave facility due to history of drug use while out on facility leave. During an interview on 3/4/26 at 7:32 A.M., Certified Nursing Assistant (CNA) #2 and CNA #3 said that no residents on the unit can leave the facility or go outside without being supervised. During an interview on 3/4/26 at 7:34 A.M., CNA #1 said that no residents can leave the facility or sit outside by themselves without being supervised. During an interview on 3/4/26 at 7:40 A.M., Nurse #2 said that Residents on the unit cannot leave the facility or go outside unsupervised. Nurse #2 said that some residents are allowed to go downstairs to activities independently. During an interview on 3/4/26 at 7:49 A.M., Resident #134 said that he/she feels like a child because he/she has not been able to leave the building or even sit outside by himself/herself. Resident #134 said that he/she has been asking for months about being able to leave independently. During an interview on 3/4/26 at approximately 8:00 A.M., Unit Manager #1 said that residents who were alert and oriented and were their own decision makers could leave the building unsupervised if there was a physician's order saying so. When asked if Resident #134 could leave the building independently he said he would have to check to see if he/she had an order. During an interview on 3/4/26 at 8:34 A.M., Social Worker #1 said that residents who were alert and oriented times three and were their own decision makers could leave the facility independently if there was a physician's order. Social Worker #1 said that some residents cannot leave the facility unsupervised despite being their own decision makers. Social Worker #1 says this was done for safety reasons and to maintain the wellbeing of residents while they were in the community and to make sure they did not bring contraband back. Social Worker #1 said Resident #134 had asked her in the past what he/she would have to do to be able to leave independently. During an interview on 3/4/26 at 8:55 A.M., the Regional Clinical Nurse and the Administrator said that residents who are alert and oriented times three and were their own decision makers were allowed to leave the building and sit outside independently with a physician's order. The Regional Clinical Nurse and the Administrator said they have had concerns about Resident #134's safety due to past behaviors and being found with contraband in his/her possession. The Administrator and the Regional Clinical Nurse said there have been conversations with him/her about being able to leave the building or sit outside, but with supervision.

Based on record review and interviews, the facility failed to formulate an advance directive for one Resident (#85) out of a sample of 37 Residents. Specifically, the facility failed to include an antipsychotic medication in a [NAME] treatment plan (a court-approved, legally mandated document authorizing a guardian to make decisions about extraordinary medical treatment, primarily antipsychotic medication for an incapacitated person who cannot consent to their own care).Findings include:Review of the facility policy titled Advance Directives, undated, indicated the following:-Advance directives will be respected in accordance with state law and facility policy.-If the Resident is incapacitated and unable to receive his or her information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.-Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan. Resident #85 was admitted to the facility in October 2023 with diagnoses including schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/20/26, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of possible 15 indicating severe cognitive impairment. Review of Resident #85's medical record indicated a Guardianship decree dated 11/30/22. Review of Resident #85's Amended [NAME] Treatment Plan with an expiration date of 7/15/26 indicated the following:-Paliperidone (Invega, an antipsychotic) Sustenna,117 milligrams-234 milligrams IM (intramuscular) every 1-4 weeks. A review of Resident #85's March 2026 physician's orders indicated the following:-Paliperidone ER Oral Tablet Extended Release 24 Hour 1.5 Milligram (Paliperidone), give 1 tablet by mouth two times a day related to Schizoaffective disorder. Start date:1/9/26. A review of Resident #85's March 2026 Medication Administration Record (MAR) indicated that staff administered the medication as ordered. During an interview and record review on 3/5/26 at 8:18 A.M., Social Worker #1 said Resident #85 should not be administered an antipsychotic medication that is not on the [NAME] treatment plan. Social Worker #1 said the Resident was currently being administered Invega by mouth, but the [NAME] treatment plan has only given permission for the Resident to be administered Invega intramuscularly. Social Worker #1 said that she has to start the paperwork to go back to court to add the correct medication on the [NAME] treatment plan. During an interview on 3/5/26 at 8:27 A.M., the Director of Nurses said the Resident should not be administered medication that was not listed on the [NAME] treatment plan. During an interview and record review on 3/5/26 at 12:19 P.M., the Corporate Social Worker/Administrator consultant said the by mouth Invega that the Resident was already being administered should have been added to the [NAME] Treatment plan prior to administering the medication.

Based on interview and record review, the facility failed to notify the physician of a significant change in the resident's mental health. Specifically, for Resident #8, the facility failed to notify the physician of vocalized suicidal ideations. Findings include: Review of the facility policy titled Change in a Resident's Condition or Status dated revised February 2021 indicated that the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Resident #8 was admitted to the facility in April 2023 with diagnoses including alcohol induced mood disorder, Wernicke's encephalopathy and bipolar disorder. Review of the minimum Data Set assessment dated [DATE] indicated that Resident #8 is moderately cognitively impaired scoring a 10 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #8 scored a 14 on the Resident Mood Interview (PHQ-2 to 9), indicating moderate depression. Review of the nursing progress note dated 2/17/26 at 10:22 A.M., indicated that Resident #8 told staff that he/she wanted to kill him/herself and that GOD had already approved this. Review of the social service progress note dated 2/17/26 at 15:29 P.M., indicated that Resident #8 had made the statement I should die to nursing. Review of the health status note dated 2/19/26 at 14:25 P.M., indicated the following: Specialty Program Director met for therapeutic support. Resident #8's thoughts are grandiose, delusional and inconsistent. He/she remains obsessed with the idea of turning this facility into a nursery for children and plants. The resident was slightly escalated this morning, more settled as the day progressed. Further review failed to indicate that the topic of recent suicidal ideations was addressed. Review of the medical record failed to indicate that Resident #8 was seen by psychiatry after making suicidal statements. Review of the care plan failed to indicate a focus for suicidal ideations or interventions to address the suicidal ideations. During an interview on 3/3/26 at 2:34 P.M., Unit Manager #2 said that when a resident vocalizes suicidal ideations I notify the administrator, the Director of Nursing, the nurse practitioner and the Specialty program Director. Unit Manager #2 then said that the Resident would be put on one-to-one supervision. During an interview on 3/3/26 at 2:51 P.M., Unit Manager #2 said that I notified the Administrator, the acting Director of Nursing and the Behavioral Director. Review of the medical record failed to indicate that the physician or a nurse practitioner was notified of the Resident's suicidal ideations. During an interview on 3/04/26 at 9:19 A.M., Nurse Practitioner (NP) #1 said that she was not notified of Resident #8's suicidal ideations until 3/3/26. NP #1 said that she should have been notified and psych services should have been notified. NP #1 said that the Resident should have been placed on one-to-one supervision. NP #1 said that a qualified, licensed practitioner would need to evaluate Resident #8 face to face before determining the Resident was safe to come off of one-to-one supervision. During an interview on 3/4/26 at 12:05 P.M., the Specialty Program Director said that he was not informed that Resident #8 had vocalized suicidal ideations. He then said that he should have been made aware.

Based on observations, interviews and record review, the facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for one Resident (#127) out of a total sample of 37 Residents.Findings Include:Review of facility policy titled Use of Restraints, dated as revised April 2017, indicated the following:-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.-Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessments shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms. Resident #127 was admitted to the facility in July 2025 with diagnoses that included malignant neoplasm of the brain, muscle weakness and history of falling. Review of the Minimum Data Set (MDS) assessment, dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. The MDS failed to indicate restraints were utilized. During an interview and observation on 3/3/26 at 9:06 A.M., the surveyor observed Resident #127 awake in bed. The left side of the bed was close to the wall and heater with no room to exit the left side of the bed. On the right side, there were multiple pillows under the fitted sheet along the right side of the Resident. The Resident said, the staff think I am going to escape out of the bed. On 3/4/26 at 7:07 A.M., 8:17 A.M. and 11:11 A.M., the surveyor observed Resident #127 awake in bed. The left side of the bed was close to the wall and heater with no room to exit the left side of the bed. On the right side, there was multiple pillows under the fitted sheet along the right side of the Resident. On 3/5/36 at 6:31 A.M., the surveyor observed Resident #127 awake in bed. The left side of the bed was close to the wall and heater with no room to exit the left side of the bed. On the right side, there were multiple pillows under the fitted sheet along the right side of the Resident. Review of the medical record failed to indicate that an assessment was completed to assess whether the use of pillows under the fitted mattress could be a restraint. Review of the active care plan failed to indicate the use of pillows under a fitted sheet for positioning purposes or as a potential restraint. Review of physician's orders failed to indicate orders for pillows under the fitted sheet or any other type of potential restraint. During an interview on 3/5/26 at 6:35 A.M., Certified Nurse Aide (CNA) #8 said that sometimes the Resident swings his/her legs over the side of the bed so she puts pillows under the sheet so that he/she cannot do that. She said the pillows help to keep him/her in bed. She said she puts them under the sheet so that he/she can't remove them. During an interview on 3/5/26 at 6:37 A.M., Nurse #9 said that he works overnight on the unit. He said that Resident #127 had poor muscle coordination, so the pillows help keep his/her legs and arms in the bed. He further said that the use of the pillows in that manner should be assessed to show that it was not functioning as a restraint for the Resident. During an interview on 3/5/26 at 8:50 A.M., Nurse #7 said that she was not sure if anyone assessed Resident #127 to determine if the use of pillows could be a restraint, but she could see why it could be considered a restraint. During an interview on 3/5/26 at 12:31 P.M., Unit Manager #3 said that pillows under the fitted sheet could be considered a restraint. She said the use of them were the preference of Resident #127, but an assessment should have been completed prior to implementing the practice to ensure it would not restraint the Resident. During an interview on 3/5/26 at 1:11 P.M., the Director of Nurses said that she is not sure why the pillows were being utilized under the fitted sheet. She said a restraint assessment should be completed to indicate that it was not a restraint, and it should be included in the Resident's plan of care.

Based on observation, record review and interview, the facility failed to develop and implement a plan of care for two Residents (#8 and #175) out of 37 residents. Specifically:For Resident #8 the facility failed to develop a plan of care for the vocalization of suicidal ideations.For Resident #175 to facility failed to implement a plan of care for assist with eating. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated revised March 2022 indicated that the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. Resident #8 was admitted to the facility in April 2023 with diagnoses including alcohol induced mood disorder, Wernicke's encephalopathy and bipolar disorder. Review of the minimum Data Set assessment dated [DATE] indicated that Resident #8 is moderately cognitively impaired scoring a 10 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #8 scored a 14 on the Resident Mood Interview (PHQ-2 to 9), indicating moderate depression. Review of the nursing progress note dated 2/17/26 at 10:22 A.M., indicated that Resident #8 told staff that he/she wanted to kill him/herself and that GOD had already approved this. Review of the social service progress note dated 2/17/26 at 15:29 P.M., indicated that Resident #8 had made the statement I should die to nursing. Review of the health status note dated 2/19/26 at 14:25 P.M., indicated the following: Specialty Program Director met for therapeutic support. Resident #8's thoughts are grandiose, delusional and inconsistent. He/she remains obsessed with the idea of turning this facility into a nursery for children and plants. The resident was slightly escalated this morning, more settled as the day progressed. Further review failed to indicate that the topic of recent suicidal ideations was addressed. Review of the care plan failed to indicate a focus for suicidal ideations or interventions to address the suicidal ideations. During an interview on 3/3/26 at 2:51 P.M., Unit Manager #2 said that I notified the Administrator, the acting Director of Nursing and the Behavioral Director. Unit Manager then said that a care plan should have been developed to address the vocalizations of suicidal ideations. During an interview on 3/4/26 at 12:05 P.M., the Specialty Program Director said that he was not informed that Resident #8 had vocalized suicidal ideations. He then said that he should have been made aware. The Specialty Program Director then said that a plan of care should have been developed to address the vocalized suicidal ideations. 2. Resident #175 was admitted to the facility in October 2018 with diagnoses including dysphagia (difficulty swallowing), Review of the Minimum Data Set assessment dated [DATE] indicated Resident #175 is severely cognitively impaired, scoring a 0 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that resident #175 is totally dependent on staff for all ADL's (activities of daily living). Review of the current care plan indicated a focus of ADL self-care performance deficit with an intervention of I require hands on assistance for eating and drinking. Review of the Kardex (a document indicating the level of care a resident requires) dated as of 3/4/26 indicated that Resident #175 requires hands on assistance for eating and drinking. On 3/3/26 at 8:50 A.M., the surveyor observed Resident #175 alone in his/her room with the door closed and with a food tray in front of him/her on the over the bed table. The surveyor also observed that Resident #175 was sleeping. On 3/03/26 at 12:51 P.M., the surveyor observed Resident #175 sitting in the dining room, asleep, with the food tray in front of him/her. After 5 minutes a Certified Nurse's Aide approached and attempted to feed Resident #175. After two attempts the CNA left the dining room. The Resident then attempted to feed him/herself unsuccessfully. The CNA returned after 2 min to assist the Resident. On 3/04/26 at 8:03 A.M., the surveyor observed Resident #175 lying in bed with a breakfast tray on an over the bed table in front of him/her. On 3/04/26 at 8:15 A.M., through 9:05 A.M., the surveyor observed Resident #175 alone in his/her room sleeping with meal in front of him/her. Resident #175 was observed holding the spoon in his/her hand and dropping the spoon in his/her lap. During an interview on 3/04/26 at 8:55 A.M., Certified Nurse's Aide (CNA) #5 said that she was not sure where to find the level of assistance a resident need when eating. CNA #5 then looked for a book of Kardex's behind the nurse's station but could not locate one. During an interview on 3/4/26 at 9:05 A.M., Unit Manager #2 said that residents that require an assist with eating should have a staff member in the room assisting the resident. Unit Manager #2 then said that Resident #175 should have a staff member assisting him/her with his/her meal. Unit Manager #2 then said that the CNAs can locate a resident's required level of assist in the Kardex, in the computer. On 3/4/26 9:26 AM the surveyor observed Unit Manger #2 enter Resident #175's room and assist Resident #175 with his/her breakfast, more than an hour and a half after Resident #175 received his/her meal.

Based on observations, record review and interviews the facility failed to ensure two Residents (#148 and #105), who are unable to carry out activities of daily living, received the necessary services to maintain good grooming and hygiene out of a total sample of 37 residents. Specifically,1. For Resident #105 the facility failed to provide incontinence care as indicated in the plan of care. 2. For Resident #105 the facility failed to remove unwanted facial hair.3.For Resident #148 the facility failed to provide nail care.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated 4/25, indicated the following: -Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) c. elimination (toileting) -The refusal and details of the interventions refused are documented in the resident's clinical record. 1.Resident #105 was admitted to the facility in February 2022 with diagnoses including Parkinson's Disease, heart failure and urinary incontinence. Review of Resident #105's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #105 had severe cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 7 out of a possible score of 15. The MDS further indicated the following: -Resident #105 was dependent on staff for all daily care and the Resident had not exhibited behaviors related to rejection of care. -Resident #105 was documented as always being incontinent of urine and bowel. -Resident #105 was a risk for pressure ulcers/injuries During an interview on 3/3/26 at 9:22 A.M., Resident #105 said there were times that he/she will not get changed by the Certified Nursing Assistants (CNAs) that work the overnight shift. Resident #105 said he/she was told that the facility was short staffed and he/she was left unchanged for twelve to thirteen hours. Resident #105 also said that the CNAs were changing him/her before lunch and after dinner. Resident #105 said when he/she pushes his/her call light for incontinence care the CNAs come in and say they will be back but never return. He/she further said that because the CNAs never return, he/she doesn't bother calling anymore. Review of Resident #105's plan of care, dated 5/15/25, indicated the following: -Focus: I have urinary incontinence related to Parkinson's Disease. -Intervention: Check resident approximately every 2 hours and provide incontinence care as needed. -Focus: I have potential for skin breakdown and or/actual breakdown related to impaired mobility, and incontinence. -Interventions: I need reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. During an interview on 3/4/26 at 6:19 A.M., Resident #105 said he/she was changed around 5:30 A.M., by the CNAs. Resident #105 said he/she needs two incontinent briefs because he/she urinated a lot and the morning and the evening shift were putting two incontinent briefs due to his/her incontinence. Resident #105 said he/she was told by the CNAs that they use two incontinent briefs because he/she urinates a lot. The surveyor made the following continuous observations on 3/4/26: - At 6:10 A.M., Resident #105 was lying in bed sleeping. -At 6:15 A.M. the overnight nurse assigned to Resident #105 administered 6:00 A.M. medications to the Resident but did not check or provide incontinence care. - At 7:34 A.M., CNA #6 entered Resident #105's room and closed the door behind him. CNA #6 adjusted Resident up in bed and set up the bedside table for breakfast. CNA #6 said to Resident #105 he will be back by 11:00 A.M., to give him/her a shower. CNA #6 did not check for or provide incontinence care to Resident #105. -At 7:44 A.M., A CNA delivered the Residents breakfast tray and did not check for or provide incontinence care to the Resident. -At 8:19 A.M., A CNA took the breakfast tray from Resident #105's bedside table. The CNA did not check for or provide incontinence care to the Resident. -From 6:10 A.M., to 10:08 A.M. Resident #105 was lying in bed, no staff member checked for or provided incontinent care. -At 10:08 A.M., CNA #6 entered Resident #105's room and closed the door behind him. During an observation at 10:11 A.M., the surveyor observed CNA #6 provide morning care to Resident #105. CNA #6 performed a complete bed bath, including washing Resident #105's entire face and combing his/her hair. Resident #105's incontinent brief was saturated with urine. CNA #6 applied two incontinent briefs; one brief was tan and the other was blue. During an interview on 3/4/26 at 10:30 A.M., CNA #6 said Resident #105 required total assistance for ADL's and he/she never refused or declined daily care. CNA #6 said Resident #105 was usually incontinent all the time and the Resident has always been incontinent since he/she has been in the facility. CNA #6 said he uses two incontinent briefs because Resident #105 urinates a lot and double briefing is better for the staff because the incontinent pads aren't enough when a resident urinates a lot. CNA #6 said this was the first time today that he washed and changed the Resident. During an interview on 3/4/26 at 2:19 P.M., Unit Manager #1 said Resident #105 was one assistance with bathing and toileting. Unit Manager #1 said the CNAs should be following the residents Kardex (a form indicating the level of care a resident needs) and getting reports from the nurses to ensure they are implementing the plan of care. Unit Manager #1 said that if resident refuses care, the CNAs should document the refusal in the electronic medical record, report the refusal to the nurse and the nurse is expected to write a progress note of the resident's refusal. Unit Manager #1 also said he would expect the CNAs to follow the care plan and perform incontinent care every 2 hours. During an interview on 3/5/26 at 10:52 A.M., the Director of Nursing (DON) and Regional Nurse Consultant said the CNAs should be assessing for incontinence every two hours and doing incontinence care if the resident was known to have frequent incontinence. The Regional Nurse Consultant said the CNAs should be making sure they offer incontinent care even if the resident refuses and double briefing is not good practice for a resident's skin. 2. Resident #105 was admitted to the facility in February 2022 with diagnoses including Parkinson's Disease and heart failure. Review of Resident #105's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #105 had severe cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 7 out of a possible score of 15. The MDS further indicated that the Resident was dependent on staff for all daily care and the Resident had not exhibited behaviors related to rejection of care. During an interview on 3/3/26 at 9:22 A.M., Resident #105 said the Certified Nursing Assistants (CNAs) have removed his/her facial hair when the hair gets too long but they haven't got around to it lately. Resident #105 said he/she would like it removed but needs assistance. On 3/3/26 at 9:22 A.M., and 1:45 P.M., 3/4/26 at 6:10 A.M., and 10:11 A.M., Resident #105 was observed with chin hair. Review of Resident #105's nursing progress notes failed to indicate he/she refused assistance with facial hair removal. On 3/4/26 at 10:11 A.M., the surveyor observed CNA #6 provide morning care to Resident #105. CNA #6 performed a complete bed bath, including washing Resident #105's entire face and combing his/her hair. CNA #6 failed to offer or provide assistance with facial hair removal. During an interview on 3/4/26 at 10:30 A.M., CNA #6 said Resident #105 is total assistance for ADL's and he/she never refuses or declines daily care. CNA #6 said shaving residents with facial hair is part of the Resident's morning care. During an interview on 3/4/26 at 2:19 P.M., Unit Manager #1 said Resident #105 is a one assist for bathing and that it is the responsibility of the CNAs to remove unwanted facial hair while providing care to the residents. Unit Manager #1 also said that if resident's refuse care, the CNA's would document the refusal in the electronic medical record, report the refusal to the nurse and the nurse is expected to write a progress note of the resident's refusal. During an interview on 3/5/26 at 10:52 A.M., the Director of Nursing said she would expect unwanted facial hair to be removed during routine care. 3. Resident #148 was admitted to the facility in November 2025 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, carpal tunnel syndrome and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of the MDS indicated functional limitations in range of motion to the upper and lower extremity, impairment to one side. Further, the MDS indicated that the Resident was dependent for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands. The MDS failed to indicate refusal of care was exhibited by the Resident. On 3/3/26 at 8:22 A.M., the surveyor observed the Resident awake in bed. The surveyor observed that on the Resident's right hand there was a brown substance under his/her fingernails. The surveyor was unable to observe the fingernails on the left hand due to a tight fist. On 3/4/26 at 8:44 A.M., the surveyor observed the Resident sleeping in bed. The Resident's right hand had a brown substance under his/her fingernails. The surveyor was unable to observe left hand due to a tight fist. On 3/4/26 at 11:09 A.M., the surveyor observed the Resident awake in bed. The Resident said that he/she had been washed up already by the aid. The surveyor observed the Resident's right hand had a brown substance under his/her fingernails. The surveyor was unable to observe left hand due to a tight fist. On 3/5/26 at 6:49 A.M., the surveyor observed the Resident sleeping in bed. The Resident's right hand had a brown substance under his/her fingernails. The surveyor was unable to observe left hand due to a tight fist. Review of Resident #148's active activities of daily living (ADL) care plan, dated 11/12/25, indicated that the Resident required the assistance of two staff members for bathing. Review of Resident 148's personal hygiene Certified Nurse Aide (CNA) documentation over the last 14 days failed to indicate that the Resident refused care. During an interview on 3/5/26 at 7:06 A.M., CNA#2 and CNA #9 said that ADL care includes not only washing the residents but also checking and cleaning under their nails and brushing their hair and teeth. They said if any portion of the ADL was refused by the resident it would be documented in the medical record. During an interview on 3/5/26 at 12:34 P.M., Unit Manager #3 said that nail care if a part of ADL care every day. She said if anything is refused by the Resident then it needs to be documented in the medical record. She said she is not aware of Resident #148 refusing any care. During an interview on 3/5/26 at 1:06 P.M., the Director of Nurses said that CNAs should be checking fingernails during ADL care and keeping them clean. Ref. F725

Based on observation, record review and interview the facility failed to implement treatment orders as recommended by the Wound Physician for one Resident (#173) out of a total of 37 sampled residents. Specifically, the facility failed to implement hydrogel orders for Resident #173's skin tear timely. Findings include: Review of the facility policy titled Wound Care dated as revised October 2010 indicated: Verify there is a physician's order for this procedure. Resident #173 was admitted to the facility in November 2019 with diagnoses including unspecified dementia, chronic obstructive pulmonary disease and major depressive disorder. Review of the Minimum Set assessment (MDS), dated [DATE], indicated Resident #173 had severe cognitive impairment as evidenced by a score of two out of a possible 15 on the Brief Interview for Mental Status Exam. Additional review of the MDS indicated Resident #173 was dependent on staff for all activities of daily living. On 3/3/26 at approximately 8:15 A.M., the surveyor observed Resident #173 resting in bed. Resident #173 was unable to engage in the interview process. Review of Resident #173's incident reports indicated on 1/22/26, Resident #173 sustained a skin tear to his/her hip from his/her brief. Review of the clinical record indicated Resident #173's wound was being monitored by the Wound Physician. Review of the Wound Physician note dated 1/29/26 indicated a skin tear that measured 2.2 CM (centimeters) X 3 CM X .05 CM. Primary Dressings: Hydrogel gel apply once daily and as needed; if saturated, soiled or dislodged. Gauze island with bdr apply once daily and as needed. Review of Resident #173's physicians orders indicated: Skin tear on left hip (trochanter): Cleanse site with normal saline, pat dry, apply calcium alginate and cover with gauze island, every day shift for wound care; active 1/24/26 through 2/6/26.Skin tear on left hip(trochanter): Cleanse site with normal saline, pat dry, apply hydrogel, then non-sterile gauze sponge and cover with gauze island once daily. Initiated 2/7/26. The Wound Physician's treatment was not implemented as ordered until 2/7/26, 9 days after it was recommended. During an interview on 3/4/26 at 10:50 A.M., Nurse #4 said that a nurse will round with the Wound Physician and then inputs the treatments as orders into the electronic record. During an interview on 3/4/26 at 1:43 P.M., Nurse #5 said that the Wound Physician comes into the building on Thursdays and uploads her notes into the record. Nurse #5 said the nurse who rounds with the Wound Physician is responsible to input the treatment recommendations as orders into the electronic health record. During an interview on 3/4/26 at approximately 2:00 P.M., Unit Manager #1 said that the Wound Physician rounds with the nursing staff and the nurse will input the treatments as orders into the record. Unit Manager #1 said that the orders were reviewed and approved by the attending physician or nurse practitioner, and he has never seen them disagree with the treatment recommendations. Unit Manager was not aware of the delay in implementing Resident #173's hydrogel order. During an interview on 3/5/26 at 11:39 A.M., the Director of Nursing (DON) said the wound doctor comes in weekly and tells the nursing staff of her new recommendations for each wound. The DON said then nursing will then update the physician order. During an interview on 3/5/226 at 12:33 P.M., the Wound Physician said that she rounds the facility weekly with nursing staff who then put in the treatment recommendations as orders. The Wound Physician said that she is in contact with the facility nurse practitioner and the nurse practitioner defers to her for treatments. The Wound Physician said she expects wound treatments be implemented timely. The Wound Physician was not aware the implementation for the use of hydrogel for Resident #173's skin tear was delayed.

Based on observation, record review and interview, the facility failed to ensure nursing implemented a splinting device as ordered for contracture prevention for one Resident (#148) out of a total sample of 37 residents. Specifically, the facility failed to ensure Resident #148 was wearing a hand roll as ordered and recommended by the therapy department. Findings include:Resident #148 was admitted to the facility in November 2025 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, carpal tunnel syndrome and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of the MDS indicated functional limitations to range of motion to the upper and lower extremity, impairment to one side. The MDS failed to indicate refusal of care was exhibited by the Resident. Review of the Occupational Therapy Discharge summary, dated [DATE], indicated the following:-STG (short term goal) #4 met on 2/12/26: Pt (patient) will tolerate WHO (wrist hand orthosis) up to 4 hours/day without redness, skin breakdown, edema for decreased contracture risk. Review of the Occupational Therapy (OT) Treatment Encounter note, dated 2/16/26, indicated the following:-Pt (patient) was edu (educated) on dc (discharge) from therapy services due to max potential achieved. Patient was edu on splinting scheduled to continue with upon OT dc. Patient is to wear splint overnight from 8pm-8am. Nursing team notified and orders were placed in [electronic medical record]. [sic] Review of physician's orders, dated 2/17/26, indicated the following:-Assist patient with doffing LUE (left upper extremity) resting hand splint for contracture management at 8am. [sic]-Assist patient with donning LUE resting hand splint for contracture management at 8pm for overnight wear. [sic] Review of February and March 2026 TAR indicated use of the orthotic. Review of the Resident's active care plan failed to indicate use of any orthotic device. On 3/4/26 at 7:05 A.M., the surveyor observed the Resident sleeping in bed with his/her arms under a blanket. The surveyor asked Resident #148 if he/she was utilizing a brace or orthotic device at this time and they responded, yes. The surveyor observed the left hand, and no device was in use, or visible in the Resident's room. The Resident's left hand was in a tight fist, and no hand splint or orthotic device was in place. On 3/5/26 at 6:30 A.M., the surveyor observed the Resident awake in bed. The Resident's left hand was in a tight fist, and no hand splint or orthotic device was in place. On 3/5/26 at 8:42 A.M., during an observation of Resident #148's room, no orthotic device or brace was seen. During an interview on 3/5/26 at 6:43 A.M., Certified Nurse Aide (CNA) #7 said that she worked overnight and took care of Resident #148. She said that the Resident does not wear anything on his/her left hand. She said she has never seen anything applied to the Resident's left hand. During an interview on 3/5/26 at 7:04 A.M., Nurse #9 said that he worked overnight and Resident #148 had not had any type of brace or orthotic on his/her left hand. During a phone interview on 3/5/26 at 10:46 A.M., the Regional Director of Rehab said that Resident #148 was on services, and upon discharge recommendations were made for a hand roll, with an eventual goal of using a splint to prevent contracture formation of the left hand. She said nursing should have been implementing the hand roll, but that she was unable to find any hand roll or splint in the Resident's room. She said if they did not have a roll or splint, nursing should have made them aware. During an interview on 3/5/26 at 12:36 P.M., Unit Manager #3 said that nursing should be implementing splinting as indicated in the physician's orders and as recommended by the therapy department. She said that if they did not have a splint then it should be reported. She said that she was not provided any type of education on the splinting plan for Resident #148 from the rehab department. During an interview on 3/5/26 at 12:49 P.M., Rehab Staff #2 said that today a brace was provided to Resident #148 because she did not have one available for use in her room. She said rehab will continue trialing it and provide education to the staff. During an interview on 3/5/26 at 1:07 P.M., the Director of Nurses said that nursing should be implementing the hand splint as indicated in the recommendations from therapy and physician's orders to prevent a contracture.

Based on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically: 1. The facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. 2. The facility failed to ensure staff appropriately donned (put on) a precaution gown while performing wound care for a Resident on enhanced barrier precautions (EBP). 3. The facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care. Findings include: 1. Review of the facility policy titled Infection Control - surveillance, revised and dated February 2023, indicated the following: - The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. - Infections that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment b. Available processes and procedures that prevent or reduce the spread of infection c. clinically significant morbidity or mortality associated with infection d. Pathogens associated with serious outbreaks Data Collection and Recording: - For Residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information b. diagnoses c. admitted , date of onset of infection (may list onset symptoms) d. Infection site e. Pathogens f. Invasive procedures or risk factors g. Pertinent remarks h. Treatment measures and precautions Review of the facility's Facility Assessment, dated 3/20/25, indicated the following: - The IP will gather data for infection tracking & reporting and provide consultation and education as needed. - The IP or designee will monitor the residents with infections and/or potential infections by completing the Monthly Infection Report by Unit. - The IP will review the infection report monthly for trends and new bacteria in the facility. Review of the facility's binder titled Infection Control Line Listings provided by the Director of Nursing who is also the Infection Preventionist (IP) indicated documents titled Monthly Infection Control Log (Line List) for the months of December 2023, January 2024, February 2024 and March 2024. Each Monthly Line Listing indicated Residents with infections, Resident location, type of infection, body site, date of infection onset, the type of organism, antibiotic information with start/stop dates, classification and resolved date - of which, some sections were completed and others were left blank. The Infection Control Line Listing Binder did not contain any Infection Control Surveillance information after March 2024. During an interview on 4/2/25 at 10:57 A.M., the Director of Nursing (DON), who is also the IP, said there is another IP in the facility who should be competing monthly surveillance, but they are not in the building today. The DON said she was unable to find any updated surveillance information relating to infection control, but it should have been completed to track the infections in the building. When the surveyor asked about the infection control surveillance binder the DON said she doesn't know much about it and she found it in the facility's former Administrator's office and does not know who completed it back in March 2024. 48990 2. Review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/2024, indicated, but was not limited to the following: - Enhanced Barrier Precautions is applicable for residents with any of the following: Wounds. - EBP requires wearing disposable gloves and an isolation gown prior to high contact activity. - High contact resident care activities include: wound care: any skin opening requiring a dressing. Review of sign titled 'Enhanced Barrier Precautions', which is posted at the room entrance door for residents on enhanced barrier precautions, indicated, but was not limited to: - Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: wound care: any skin opening requiring a dressing. On 4/1/25 at 9:43 A.M., the surveyor observed Nurse #3 and Unit Manager #1 perform wound dressing change for a Resident with one unstageable pressure ulcer and one stage two pressure ulcer. Certified Nurse Assistant (CNA) #2 assisted with repositioning during this wound care. There was a sign at the Resident's doorway indicating the Resident titled 'Enhanced Barrier Precautions' indicating staff must wear gloves and precaution gowns during wound care. Nurse #3, Unit Manager #1, and CNA #2 all wore gloves, but did not wear precaution gowns during the entire duration of both wound dressing changes. During an interview on 4/1/25 at 9:56 A.M., Nurse #3 and Unit Manager #1 said the Resident required enhanced barrier precautions because of his/her pressure ulcers. Nurse #3 and Unit Manager #1 said they should have worn precaution gowns in addition to the gloves but did not. During an interview on 4/1/25 at 11:28 A.M., the Director of Nursing (DON) said precaution gowns, in addition to gloves, are required during wound care for any resident on enhanced barrier precautions. 3. Review of the facility policy titled 'Hand Washing', revised December 2019, indicated, but was not limited to the following: 6. Use an alcohol-based hand rub, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. a. Perform hand hygiene before and after glove use. Review of the facility policy titled 'Non-sterile Dressing Change', revised January 2023, indicated, but was not limited to the following: - Procedure: Remove soiled dressing: place it in the trash bag. Remove gloves, wash hands, apply new gloves. - Procedure: Clean wound with normal saline or prescribed cleanser. Pat the tissue surrounding the wound dry with 4x4. Remove gloves, wash hands, apply new gloves. On 4/1/25 at 9:43 A.M., the surveyor observed Nurse #3 and Unit Manager #1 perform wound dressing change for a Resident with one unstageable pressure ulcer on right ischium (the lower, back part of your hip bone) and one stage two pressure ulcer on mid back. Nurse #3 wore gloves to cleanse the right ischium pressure ulcer with normal saline. Nurse #3 removed her gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #3 applied hydrogel (a gel used to treat wounds) to right ischium wound bed. Nurse #3 removed her gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #3 applied new dressing to right ischium. Nurse #3 removed her gloves, sanitized her hands, and applied a new pair of gloves and cleansed the mid back pressure ulcer with normal saline. Nurse #3 removed her gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #3 applied hydrogel to mid back wound bed. Nurse #3 removed her gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #3 then applied dressing to mid back. Nurse #3 did not wash or sanitize her hands after removing her gloves four out of five times during this Resident's wound care. During an interview on 4/1/25 at 9:56 A.M., Nurse #3 and Unit Manager #1 said Nurse #3 should have sanitized or washed her hands each time she removed her gloves before applying new gloves but did not. During an interview on 4/1/25 at 11:28 A.M., the Director of Nursing (DON) said the nurse's hands should have been washed or sanitized every time gloves were removed during wound care.

Based on record review and interview the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were addressed timely for three Residents (#21, #68, and #3) out of five residents reviewed, out of a total sample of 33 residents. Findings include: 1. Resident #21 was admitted to the facility in June 2017 and has diagnoses that include, but are not limited to, unspecified dementia with other behavioral disturbance, and Type 2 Diabetes Mellitus with diabetic neuropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident #21 had a staff assessment for mental status completed indicating he/she as having a moderately impaired cognition and is dependent for daily care activities. Further review of the MDS indicated Resident #21 is administered medications in the high-risk drug classes. Review of Resident #21's medical record indicated the consulting pharmacist monthly MRR, dated 8/27/24, 9/23/24, and 10/28/24, recommended an A1C f/u. (An A1C is a blood test that measures the average blood glucose levels. It is used to monitor how well diabetes plans are working). Record review indicated a laboratory report, dated 10/28/25, with an A1C of 7.5 (high) was obtained 63 days after the pharmacist made the recommendation to follow up with an A1C. During an interview on 4/1/25 at 2:19 P.M., Nurse #4 said the pharmacy recommendations are sent to the Director of Nursing, reviewed with the doctor, and then followed through or a reason is given by the doctor if they do not agree with the recommendation. Nurse #4 said the recommendation to get an A1C for Resident #21 is because he/she is diabetic. Nurse #4 reviewed the record and said the only lab result was dated 10/28/25 and she did not know why the recommendation was not followed up on. 2. Resident #68 was admitted to the facility in October 2018 and has diagnoses that include, but are not limited to, unspecified dementia, type 2 diabetes mellitus, acute kidney failure, unspecified protein calorie malnutrition and hyperlipidemia. Review of Resident #68's MDS, dated [DATE], indicated Resident #68 as having severe cognitive impairment and as dependent on staff for most daily care activities. Review of Resident #68's medical record indicated the consulting pharmacist monthly MRR, dated 10/28/24, 11/25/24, 12/23/24 1/27/25 and 2/24/25, indicated 'nursing rec for BMP CBC f/u'. (A BMP CBC is a blood test that measures amounts and sizes of red blood cells, hemoglobin, white blood cells, and platelets. Providers use it to diagnose and monitor medial conditions). Further review of Resident #68's medical record indicated results of a BMP CBC, dated 2/28/25, which was completed four months after the pharmacist made the first recommendation for a BMP CBC. During an interview on 4/1/25 at 2:19 P.M., Nurse #4 said the pharmacy recommendations are sent to the Director of Nursing, reviewed with the doctor, and then followed through or a reason is given by the doctor if they do not agree with the recommendation. Nurse #4 said Resident #68 had been on hospice care and that she did not know if that was why the recommendation for labs were not followed. During an interview on 4/2/25 at 8:31 A.M., and 11:10 A.M., Regional Nurse #1 said her review of the medical record and pharmacy binder in the DON's office did not indicate why the recommendations for obtaining laboratory values for Resident #21 and Resident #68 were not completed. Regional Nurse #1 said the pharmacy recommendations should be followed up timely and/or include why they may not have been implemented. 45984 3. Resident #3 was admitted to the facility in April 2023 with diagnoses including schizoaffective disorder and cerebral palsy. Review of Resident #3's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident has a Brief Interview for Mental Status score of 12 out of 15 indicating moderate cognitive impairment. Review of Resident #3's medical record indicated the consulting pharmacist monthly MRR, dated 11/26/24, 12/23/24, 1/27/25 and 2/24/25, indicated the following: Rec (Recommend) Nursing: lipids, A1C (An A1C is a blood test that measures the average blood glucose levels. It is used to monitor how well diabetes plans are working). Review of Resident #3's lab results history indicated that the Resident had his/her lipid panel and A1C values obtained on 3/5/25, over three months after the pharmacist made the initial recommendation. During an interview on 4/1/25 at 2:19 P.M., Nurse #4 said the pharmacy recommendations are sent to the Director of Nursing, reviewed with the doctor, and then followed through or a reason is given by the doctor if they do not agree with the recommendation. During an interview on 4/1/25 at 12:05 A.M., the Director of Nursing (DON) said when the pharmacist makes recommendations they should be acknowledged immediately and then sent to the physician for approval/disapproval and then get implemented right away. The DON said Resident #3's pharmacy recommendations should have been done sooner.

Based on observation, record review and interview, the facility failed to ensure six Residents (#12, #70, #88, #146, #77 and #94) received care in accordance with professional standards of practice, out of a total sample of 33 residents. Specifically, 1. For Resident #12, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 2. For Resident #70, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 3. For Resident #88, the facility failed to ensure nursing obtained a physician order for the use of his/her air mattress. 4. For Resident #146, the facility failed to ensure nursing applied ace wraps as per the physician's order. 5. For Resident #77, the facility failed to ensure staff applied a palm guard as per the physician's order. 6. For Resident #94, the facility failed to ensure physician's orders were transcribed correctly. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #12 was admitted to the facility in December 2021 with diagnoses that included Parkinson's disease, dementia, major depressive disorder, and adult failure to thrive. Review of Resident #12's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have moderate cognitive impairments. Further review of the MDS indicated he/she is at risk for developing pressure ulcers. Review of Resident #12's physician order, dated 9/1/23, indicated Weekly Skin Check every day shift every Fri (Friday). Review of Resident #12's evaluation tab in the electronic medical record (EMR) indicated the last skin check that was completed was 3/14/25. Review of Resident #12's March 2025 Treatment Administration Record (TAR) indicated on 3/21/25 and 3/28/25 nursing staff marked on the TAR as the weekly skin check was completed. Review of Resident #12's skin care plan, dated 1/16/24, indicated Weekly skin evaluations. Review of Resident #12's Norton Scale for Predicting Risk of Pressure Ulcer, dated 3/3/25, indicated he/she scored an 11 indicating moderate risk. Review of Resident #12's March 2025 nursing progress notes failed to indicate the Resident refused or that nursing completed the weekly skin check on 3/21/25 and 3/28/25. During an interview on 4/2/25 at 7:27 A.M., Nurse #4 said nursing should be filling out a skin check weekly as ordered in the EMR and documenting that on a skin check assessment in the evaluations tab in the EMR. During an interview on 4/2/25 at 9:14 A.M., the Director of Nursing (DON) said nursing staff should follow the doctors order and complete the skin check under the evaluations tab in the electronic medical record. 2. Resident #70 was admitted to the facility in July 2014 with diagnoses that included dementia, delusional disorders, heart failure, and major depressive disorder. Review of Resident #70's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated he/she is at risk for developing pressure ulcers. Review of Resident #70's physician order, dated 9/4/23, indicated Weekly Skin Check every day shift every Mon (Monday). Review of Resident #70's evaluation tab in the electronic medical record (EMR) indicated the last skin check that was completed was 3/14/25. Review of Resident #70's March 2025 Treatment Administration Record (TAR) indicated on 3/24/25 and 3/31/25 nursing staff marked on the TAR as the weekly skin check was completed. Review of Resident #70's skin care plan, dated 1/15/24, indicated Weekly skin evaluations. Review of Resident #70's Norton Scale for Predicting Risk of Pressure Ulcer, dated 3/24/25, indicated he/she scored a 6 indicating high risk. During an interview on 4/2/25 at 7:27 A.M., Nurse #4 said nursing should be filling out a skin check weekly as ordered in the EMR and documenting that on a skin check assessment in the evaluations tab in the EMR. During an interview on 4/2/25 at 9:14 A.M., the Director of Nursing (DON) said nursing staff should follow the doctors order and complete the skin check under the evaluations tab in the electronic medical record. 3. Review of the facility policy titled Pressure Relieving Devices, dated January 2023, indicated Appropriate Pressure Reduction devices will be available in each facility. Standard for proper inflation of specialty surfaces - a. Follow manufacturer's instruction for proper inflation of surfaces. b. Staff must be trained to monitor for proper setting on inflation devices. The proper setting may be attached to the actual monitor at each bed. Resident #88 was admitted to the facility in September 2023 with diagnoses that included dementia, adult failure to thrive, cognitive communication deficit, and pain disorder. Review of Resident #88's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she was assessed by nursing staff to have moderate cognitive impairments. Further review of the MDS indicated he/she is at risk for developing pressure ulcers. On 3/31/25 at 7:58 A.M. and 4/1/25 at 7:28 A.M., the surveyor observed Resident #88 in bed on an air mattress. The air mattress was set to the highest setting. Review of Resident #88's active physician orders failed to indicate an order for the use of his/her air mattress. During an interview on 4/2/25 at 7:19 A.M., Nurse #4 said the Resident has been on an air mattress for so long and said the air mattress should have a doctors order in place. During an interview on 4/2/25 at 9:18 A.M., the Director of Nursing said a Resident who has an air mattress on their bed should have a doctors order in place with settings. 43807 4. Resident #146 was admitted to the facility in August 2024 with diagnoses including edema. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition. During an interview on 3/31/25 at 8:18 A.M., Resident #146 said he/she has edema in his/her legs. He/she said both his/her legs should be wrapped daily in the morning and unwrapped in the evening. Resident #146 said his/her legs are not wrapped daily. A review of Resident #146's April 2025 physician's orders indicated the following: - Ace wrap to BLE (Bilateral Lower Extremity) apply daily in AM (morning), off at HS (at bedtime) one time a day. Apply Ace wrap daily and remove at bedtime. Order date, 9/18/24. Review of Resident #146's March 2025 Treatment Administration Record (TAR) failed to indicate nursing documented the physician's order to Ace wrap daily and remove at bedtime as completed on the following time and dates: - At 6:00 A.M., on 3/2/25, 3/4/25, 3/5/25, 3/7/25, 3/9/25, 3/10/25, 3/12/25, 3/19/25, 3/21/25, 3/23/25, 3/24/25, 3/26/25, and 3/28/25. During an interview and record review on 4/2/25 at 7:12A.M., Unit Manager #1 said Nurses are expected to document in the TAR after wrapping Resident #146's legs. She said if the treatment was not documented as completed, that means the physician's order was not implemented. During an interview and record review on 4/2/25 at 8:29 A.M., the Director of Nurses (DON) said Nurses should always follow the physician's orders. The DON said if the treatment was not documented as completed, that means the physician's order was not implemented. 5. Resident #77 was admitted to the facility in July 2020 with diagnoses including hemiplegia and hemiparesis. A review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated impairment on both sides of the upper extremities. On 3/31/25 at 8:45 A.M., and 1:27 P.M., the Surveyor observed Resident #77 lying in bed. The left-hand fingers were in a balled fist. Resident #77 did not have a palm guard in his/her left hand. On 4/1/25 at 7:54 A.M., the Surveyor observed Resident #77 lying in bed. The left-hand fingers were in a balled fist. Resident #77 did not have a palm guard in his/her left hand. On 4/1/25 at 5:28 P.M., the Surveyor observed Resident #77 lying in bed. The left-hand fingers were in a balled fist. Resident #77 did not have a palm guard in his/her left hand. A review of Resident #77's April 2025 physician's orders indicated the following: - Left palm guard: DON during AM care, DOFF for hygiene and skin assessment as tolerated every shift. Order date, 8/31/23. During an interview and observation on 4/2/25 at 7:18 A.M., Certified Nurse's Assistant (CNA) #7 said Resident #77 should have a left palm guard on. CNA #7 looked around in the Resident's room and could not find the palm guard. She said the palm guard was in the laundry room. During an interview on 4/2/25 at 7:19 A.M., Resident #77 said he/she has not worn the palm guard in a few weeks. He/she said he/she needs help from staff to put on the palm guard. During an interview and observation on 4/2/25 at 7:24 A.M., Unit Manager #1 said staff should always follow the physician's orders. Unit Manager #1 said Resident #77 should have a palm guard on his/her left hand. She said the palm guard was taken to the laundry room and got lost. During an interview on 4/2/25 at 8:39 A.M., the Director of Nurses said Resident #77 should wear a left hand palm guard as ordered by the physician. 6. Resident #94 was admitted to the facility in February 2025 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS), dated [DATE], did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. Further review of the MDS indicated that the Resident has a feeding tube. A review of Resident #94's April physician's orders indicated the following: - Resident is NPO (nothing by mouth) every shift. Order date, 2/12/25. - Hydralazine HCI oral tablet 10 milligrams, give 1 tablet by mouth two times a day related to hypertension. - Metoprolol Tartarate Tablet 25 milligrams, give 0.5 tablet by mouth one time a day for hypertension. During an interview and record review on 4/2/25 at 7:40 A.M., Unit Manager #1 said Resident #94's medications in the physician's orders should not be transcribed by mouth because the Resident is NPO. During an interview and record review on 4/2/25 at 8:36 A.M., the Director of Nursing said Resident #94's physician's orders should not read by mouth because the Resident is NPO.

Based on observation, record review and interview, the facility failed to ensure staff provided care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing resident individuality for two sampled Residents (#68 and #119) out of a total of 33 sampled residents. Specifically, the facility failed to ensure staff regularly communicated with Resident #68 and Resident #119 in a language they understand. Findings include: Review of the facility's Interpreter Services policy dated February 2022 indicated: -The facility shall ensure that Limited English Proficient (LEP) residents and their families are able to effectively provide facility staff with a clear statement of their medical condition and history and understand the healthcare provider's assessment of their medical condition and treatment options. This is essential to the provision of quality resident care. -The facility shall provide language assistance services, including bilingual staff and interpreter services as no cost to each resident/consumer with limited English proficiency at all points of contact in a timely manner during al hours of operations, thus ensuring that LEP residents have available translators to assist in understanding the activities of staff members on their behalf and ensure the residents'/families' involvement in planning care, treatment and services. -LEP residents hall have services provided to them in their primary language or have interpreter services provided to them during the delivery of all significant healthcare services. 1. Resident #68 was admitted to the facility in October 2018 with diagnoses including dementia, aphasia and anxiety disorder. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #68 required a translater to communicate as his/her primary language was Korean. On 3/31/25 8:36 A.M., the surveyor observed Resident #68 resting in bed. Resident #68 could not engage in an interview or respond to questions. Review of Resident #68's care plans indicated: Focus: Risk for impaired communication secondary to Resident being non-English speaking. Primary language is Korean, dated 12/4/23. Interventions: Provide resident with communication/picture board if available. Use gestures i.e. pointing to items whenever possible. Utilize language translating hotline or interpreter as needed. Focus: Resident is at risk for social isolation secondary to being Korean speaking only (understands some English). Resident attends activity programs in day room daily. He/she needs encouragement to initiate participation, dated 1/14/2025. Interventions: Korean communication card Utilize Korean speaking translators, family members and staff to obtain interests and support daily routine. Assist and support communication with family and friends via social media. During observations of Resident #68's room on 3/31/25 and 4/1/25, the surveyor was unable to locate communication cards or picture boards. Review of the progress notes indicated: 3/10/2025: Met with Resident #68 for a wellness check after the incident with another resident who became inappropriate with him/her. Resident #68 has a dementia diagnosis, is aphasia and is Korean, he/she does understand basic questions, but during this interview he/she was unable to respond. When asked if he/she is okay and feels safe, he/she nodded yes and grabbed my hand. That was his/her only response to any of the questions. SS (Social Service) department will continue to follow up with Resident #68 and a referral to be seen by psych services has been completed. 3/11/2025: This writer met with resident in his/her room. No observable signs of trauma or stress. Limited English, but able to say he/she is doing ok. Due to cognitive deficits he/she is unable to relate to this writer the events of the previous day. Social service will continue to monitor. The progress notes failed to indicate staff utilized a translator to meet with Resident #68. On 4/1/25 at 7:33 A.M., the surveyor observed Certified Nursing Aid (CNA) #8 serve Resident #68 his/her breakfast. The CNA did not speak to or attempt to engage with Resident #68 as she arranged the breakfast tray. CNA #8 said that Resident #68 can speak some English but that he/she needs an interpreter. When asked how to obtain an interpreter, CNA #8 said that she would tell the activities lady. During an interview on 4/1/25 at 7:54 A.M., Nurse #4 said no residents on the unit speak Korean. On 4/1/25 at 7:58 A.M., the surveyor observed Resident #68 calling out and reaching his/her arms up and wave to staff passing by his/her room. Resident #68 became increasingly upset and threw his/her bed control off the bed. Nurse #6 entered the room to assist. Nurse #6 said that Resident #68 is unable to explain to staff in English what he/she wants. Nurse #6 said that staff could call an interpreter service. Nurse #6 continued to remain the room and adjust Resident #68 in bed without attempting to speak with the Resident. During an interview on 4/1/25 at 8:02 A.M., CNA #4 said that she was not sure how he/she would obtain an interpreter and she would ask the nurse. On 4/1/25 at 8:09 A.M., the surveyor observed an interpreter hotline number posted at the nurses station. Three staff members were in Resident #68's room discussing what he/she could possibly want (i.e. get up, get dressed, etc) as he/she continued to call out from the bed. During an interview on 4/1/25 at 12:25 P.M., Social Worker #1 said that Resident #68's family member can assist with translating and that staff can also use an interpreter hotline. During an interview on 4/2/25 at 9:07 A.M. the Director of Nursing (DON) said that she would expect staff to communicate with residents whose primary language is not English through an interpreter service. 2. Resident #119 was admitted to the facility in October 2024 with diagnoses including dementia and diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #119 required the use of a translator to communicate as his/her primary language was Vietnamese. During an interview on 3/31/25 at 8:15 A.M., Resident #119 was smiling but unable to engage in a conversation with the surveyor. The surveyor observed a worn communication sheet on the wall with pictures for water, pain, medication and other basic needs. Review of Resident #119's care plans indicated: Focus: Resident has impaired communication due to language barrier. Preferred language is Vietnamese, dated 1/28/25. Interventions: Enlist use of communication devices as needed communication board, sign language. Utilize language translating hotline or interpreter as needed. Focus: Resident is at risk for social isolation secondary to being Vietnamese speaking only, understands some English, dated 11/8/24. Interventions: Utilize Vietnamese speaking translators, family members and staff to obtain interests and support daily routine. Assist and support communication with family and friends via social media. During an interview on 4/1/25 at 7:41 A.M., Resident #119 was observed eating breakfast in his/her room. When asked in English how the food tasted, Resident #119 responded thank you. Review of the nurse progress notes indicated: 3/13/2025: Resident was found by CNA on the right side of the bed. Resident had difficulty to give the description of the fall due to language barrier. Resident c/o (complained of) pain prn (as needed) Tylenol given with effect, new order from on call clean area with ns bacitracin daily until Healed, Neuro checks. Safety maintained. 3/10/2025: Resident was found on the floor by CNA after dinner. Due to language barrier resident was unable to give a description of the fall. Resident sustained a small cut on the right side of his forehead, assessment completed resident was able to move all upper and lower extremities PRN Tylenol 650mg was given for discomfort with + effect. The fall was immediately reported to the On call, new order to clean area with normal saline apply bacitracin daily until healed, Neuro checks. Healthcare proxy son also notified of the fall. Safety maintained. The progress notes failed to indicate staff utilized a translator when speaking with Resident #119 after his/her falls to determine the possible cause. During an interview on 4/1/25 at 7:44 A.M., Certified Nursing Aid (CNA) #3 said Resident #119 doesn't speak English but he/she could follow directions when staff speak with him/her. CNA #3 said that Resident #119 cannot express his/her needs in English and he did not know how to get an interpreter to communicate with Resident #119. CNA #3 said he did not know what Resident #119's primary language is. During an interview on 4/1/25 at 7:54 A.M., Nurse #4 said Resident #119 can understand English and follow directions, but could not speak English. Nurse #4 was unable to articulate how to locate an interpreter to speak with residents whose primary language is not English. During an interview on 4/1/25 at 8:02 A.M., CNA #4 said that she was unsure how to get obtain an interpreter and would ask the nurse. During an interview on 4/1/25 at 12:25 P.M., Social Worker #1 said that staff can interpret for Resident #119 and staff could also utilize an interpreter hotline. During an interview on 4/2/25 at 9:07 A.M., the Director of Nursing said she would expect staff to be aware of the primary language of Resident's and utilize an interpreter service to communicate with them.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors when physician's orders for the administration of liquid [MEDICATION(S)] (narcotic, used to treat pain) where not followed, resulting in an overdose and which resulted in the need for hospitalization , for one closed record sampled Resident (#292) out of a total of three closed records reviewed. Findings include: Review of the facility's Medication Error Policy dated 2/6/21 indicated the following: Definitions: A medication error is any preventable event that may cause or lead to inappropriate medication use or resident harm. *Significant medication errors are those which require medical intervention and/or result in possible or confirmed morbidity or mortality. *Residents shall be free of any significant medication errors *All adverse medication events requiring notification through external state, federal, USP or FDA channels shall be reported according to the requirements of the specific organization. Resident #292 was admitted to the facility in January 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #292's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - 2/10/21: [MEDICATION(S)]: give 10 mg twice a day for pain, hold for sedation Review of Resident #292's nursing progress notes indicated the following: 2/23/21 10:53 A.M.; Resident appeared very lethargic and minimally responsive. Oxygen saturation 71% 2 liters. Was titrated up to 4 liters with 92%. Resident had slurred speech and right facial twitch. Bilateral upper extremities flaccid, unable to grasp or squeeze this writers hand. Pupils appears dilated. Resident did come to a little after 10 minutes or so. Able to respond to yes no questions. Oriented to self. Normally oriented x 3. Assistant Director of Nursing evaluated, recommended to send to hospital. Nurse practitioner notified, may transfer to hospital. Review of the Resident's Hospital Paperwork dated 2/28/21 indicated the following: *Resident resides at facility and the staff there reportedly noted his/her oxygen status to be in the 70's prior to calling EMS (Emergency Medical Services). Also of note, patient's roommate reports that patient received two doses of [MEDICATION(S)] instead of one, which the nursing home denied to EMS. *Apnea: On HD1 (hospital day one) had three apneic episodes that were responsive to [MEDICATION(S)] but without loss of a pulse. He/she was transferred to the ICU (intensive care unit) for possible [MEDICATION(S)] drip and her home [MEDICATION(S)] was held. He/she did not ultimately require [MEDICATION(S)] drip. It was felt that these episodes were likely due to possible extra dose of [MEDICATION(S)] per family report. *[CONDITION(S)]: Presented with significant [CONDITION(S)], likely in setting of UTI (urinary tract infection), uremia and poor substrate given prior stroke. Also possibly with opiate withdrawal given that we had originally held his/her [MEDICATION(S)] and he/she received [MEDICATION(S)] x 3. Review of the facility's investigation 2/23/21 included a photo of a liquid [MEDICATION(S)] medication bottle with a concentration of 10 MG/ML label. The label indicated: Take .5 ML (5 MG) under the tongue 3 times a day for pain, hold for sedation; which contradicted the order written by the physician. Review of the Narcotic Book indicated the following: [MEDICATION(S)] 15 MG or .5 ML three times a day and indicated that Resident #292 had received .5 ml of [MEDICATION(S)] for each dose from 2/18/21 through 2/22/21. This order also contradicted the physician's order as indicated in the Medication Administration Record. The facility's investigation concluded that Resident #292 had received 5 ml instead of .5 ml of [MEDICATION(S)] in error. The Director of Nursing (DON) was interviewed on 6/25/21 at 1:32 P.M. and on 6/29/21 at 10:20 A.M. regarding the medication error. The DON said that the facility had investigated the error and noted that the medication orders were written differently and also transcribed differently in the electronic record, paper record and narcotic book which contributed to the medication error. The DON said that during her interviews with nursing staff, they all said that despite the differing orders, they would have given Resident #292 a .5 ml dosage of [MEDICATION(S)] as indicated on the bottle. The DON acknowledged that Resident #292 receiving 5 ml from the bottle labeled 10 MG/ML resulted in Resident #292 receiving 50 mg of [MEDICATION(S)].

Based on record review and interview, the facility failed to implement timely interventions after a significant weight loss and complete a full nutrition assessment after a significant weight loss for 2 residents (#21 and #59) and failed to maintain a fluid restriction for 1 resident (#123) out of a total sample of 30 residents. Findings include: According to the policy titled Weight Policy, dated 2/7/2021, indicated the following: * Weights may be ordered more frequently if there is a significant change in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance. * Any significant change in weight compared to the previous weight should be re-checked and visually verified for accuracy by the nurse on duty before being documented in the medical record. * The Dietitian, Physician, and responsible party should be notified of significant weight changes. 1. Resident #59 was admitted in 01/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #59 was independent with feeding and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Review of the nutrition care plan indicated the following: *Problem (initiated 5/13/2021): Alteration in nutrition status related to overall decline with associated weight loss due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: * Ensure Plus 237 ml (milliliters) 3 times/day (initiated 5/13/2021) Review of the Initial Comprehensive Assessment, dated 1/23/2021, indicated that Resident #59 was at nutrition risk related to variable intake due to decline in appetite with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Weight Report indicated the following: * 1/20/2021 - 150 lbs (pounds) * 3/1/2021- 135 lbs * 4/5/2021 - 129 lbs * 5/13/2021- 131 lbs Review of the weight report indicates that from 1/20/2021 to 3/1/2021, Resident #59 went from 150 lbs to 135 lbs, which is a 10%, significant weight loss in 39 days. Review of the resident progress note, dated 4/27/2021, indicated that Resident #59 had a significant weight loss of 14% over 3 months and was on Ensure 3 times/day. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no indication in the record that any other interventions were put in place or a full comprehensive assessment was completed after the significant weight loss was identified on 3/1/2021. Resident #59 was not seen until 4/27/2021 by the Dietitian regarding the weight loss. During an interview on 6/25/2021 at 10:15 A.M., the Dietitian said that she had recently started and before her the Dietitian was covering once per week. She said she believed that the facility did not have any other coverage during the pandemic. 2. Resident #21 was admitted in 7/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nutrition care plan, dated 6/23/2021, indicated the following: * Problem- Alteration in nutritional status related to history of unplanned weight loss, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the weight record indicated the following: 10/5/2020: 117 lbs (pounds) 11/2/2020: 112.4 lbs 12/8/2020: 106.4 lbs 1/15/2021: 106.4 lbs 2/1/2021: 103.4 lbs Resident #21 had a significant weight loss from 11/2/2020 at 112.4 pounds to 12/8/2020 at 106.4 pounds, which is a significant (5.3%) weight loss in one month. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietitian's quarterly progress note, dated 12/26/2020, 18 days after the initial significant weight loss, indicated that Resident #21 had a significant weight loss and was started on Ensure twice a day. The record did not indicate that anything had been initiated to address the significant weight loss, prior to 12/22/2020, which is 14 days after the initial weight loss. There was no assessment completed between 12/22/2020 and 2/1/2021 to address the weight loss. During an interview on 6/25/2021 at 10:15 A.M., the Dietitian said that she had recently started and before her the Dietitian was covering once per week. She said she believed that the facility did not have any other coverage during the pandemic. 3. For Resident #123, the facility failed to document a fluid restriction as ordered. Resident #123 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1500 milliliter (ml) fluid restriction every shift. Dietary 240 ml at every meal = 720 ml Nursing/meds: (enter amount/med times) Free fluids (enter shift and amount Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #5 on 6/28/21 at 10:00 A.M., he stated he did not know why the fluid amounts were not documented.

Based on observation, interview and record review the facility staff failed to: 1. follow a physician's order for wound care and prevent the worsening of a wound for 1 resident (#98), 2. follow a physician's order to obtain a [MEDICATION NAME] trough level for 1 resident (#237), and 3. ensure the provision of an outside medical appointment resulting in the delay of treatment for 1 Resident (#104) out of a total sample of 40 residents. Findings include: 1. For Resident #98 the facility staff failed to follow a physician's order for wound care and prevent the worsening of a wound. Resident #98 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. The admission assessment minimum data set ((MDS) dated [DATE] indicated the Resident scored a 15 out of 15 points on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The discharge assessment-return anticipated MDS dated [DATE] indicated the Resident required assistance or supervision with most aspects of his/her activities of daily living. Review of Resident #98's hospital transfer paperwork indicated the resident had been discharged to the facility after a revision and excisional debridement (removal of damaged/necrotic tissue from a wound) to his/her right [MEDICAL CONDITION] wound on 5/30/19. The medical record indicated physician's orders dated 5/31/19 for negative pressure treatment, scheduled dressing change, irrigate wound with normal saline f/b (followed by) green foam. Change every Monday, Wednesday, and Friday on the 7:00 A.M. - 3:00 P.M. shift, and to monitor the dressing every shift for intactness and functioning set at -125 mmhg continuously. On 6/14/19 at 11:08 A.M., the surveyor observed a negative pressure wound therapy pump (a device that uses continuous suction to aid in wound healing and drainage removal) in Resident #98's room. Resident #98 was not present as he/she was out for an appointment. On 6/17/19 at 1:13 P.M., the surveyor observed a lunch tray left for Resident #98 in his/her room. The Resident was not present as he/she was out of the facility at an appointment. The negative pressure wound therapy pump was in the Resident's room. On 6/18/19 at 8:35 A.M., the surveyor observed Resident #98 in his/her wheelchair in his/her room. A dressing was on his/her right lower extremity amputation site and not connected to the negative pressure pump device. During an interview on 6/18/19 at 8:39 A.M., Resident #98 said he/she was going to a vascular appointment in the morning and then to [MEDICAL TREATMENT] in the afternoon. He/she said the pump was disconnected from the dressing because the facility staff wouldn't let him/her go on appointments or to [MEDICAL TREATMENT] with the pump (the Resident goes to a [MEDICAL TREATMENT] center three times per week for more than four hours at a time). Review of Resident #98's treatment administration record (TAR) for 6/2019 indicated the following: -6/03/19: wound site red, moderate drainage, no odor, peri-wound intact -6/05/19: wound site open, moderate drainage, no odor, peri-wound intact -6/07/19: wound site open, moderate drainage, no odor, peri-wound intact -6/10/19: wound site brown, serous drainage, odor-yes, peri-wound slough (dead tissue usually yellow in color), and looks infected. During an interview on 6/18/19 at 9:17 A.M., the assistant director of nursing (ADON) said that the facility staff do not send pumps or any rented equipment with residents when they go on appointments in case the equipment is misplaced or lost. She said that this is not following the physicians order for continuous negative pressure therapy and does create risk for complications for the Resident's wound. During an interview on 6/18/19 at 9:35 A.M., Nurse #7 said the negative pressure pump should be connected to the wound dressing to keep the negative pressure continuous to help heal the wound. She was unaware as to why the pump was disconnected from the wound dressing. During an interview on 6/18/19 at 10:35 A.M., the Director of Nursing said his expectation is that the order for continuous negative pressure would be followed for wound care, and the pump is portable and can go with the resident to appointments. Review of the vascular consult dated 6/18/19 indicated the following: -[MEDICATION NAME] debris with some forming eschar (dark, necrotic tissue) mid-portion of the wound. Minor debridement was attempted but ultimately not done secondary to patient comfort. (Progression from red beefy wound to having necrotic tissue in wound bed) -Mid-portion of wound would benefit from some enzymatic debridement. During an interview on 6/19/19 at 10 A.M., the Director of Nursing said he would expect the nurses to report a change in condition to the physician or nurse practitioner (i.e. development of slough in a wound). During an interview on 7/3/19 at 8:00 A.M., [MEDICAL TREATMENT] Nurse #1 said that residents are allowed to go to [MEDICAL TREATMENT] accompanied with necessary equipment such as a negative pressure therapy pump. 2. For Resident #237 the facility staff failed to follow a physician's order to obtain a [MEDICATION NAME] trough level. Review of the facility policy for diagnostic services dated 7/1/18 indicated the following: -All diagnostic testing/procedures shall be performed as ordered by a physician or other licensed independent practitioner. -In the event that a procedure cannot be completed timely, the physician will be notified of the potential delay so that appropriate action can be taken. Resident #237 was admitted to the facility in 6/2019 with [DIAGNOSES REDACTED]. Review of Resident #237's medical record indicated a physician's order for [MEDICATION NAME] (an antibiotic used for treating infection) 1.25 gram intravenous every 12 hours, obtain [MEDICATION NAME] trough level next fourth dose dated 6/3/19 - 6/18/19. Review of Resident #237's medical record indicated trough levels were obtained on 6/7/19 and 6/10/19, but failed to indicate any other trough levels were obtained after 6/10/19. Review of the Resident's medical record failed to indicate the [MEDICATION NAME] trough was drawn on 6/13/19, 6/15/19 and 6/17/19. During an interview on 6/19/19 at 8:44 A.M., Unit Manager #2 said the trough level was missed last Thursday 6/13/19 because he/she was at an appointment that day, and was not obtained until 6/18/19. She said it should have been called in to the physician immediately when discovered it had been missed and a trough should have been obtained immediately secondary to the risk of toxicity from elevated levels in the Resident's blood. 3. Resident #104 was admitted in 7/2008 with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE], indicated that Resident #104 scored a 15 out of 15 on the Brief Interview for Mental Status indicating that his/her cognition was intact. The Minimum (MDS) data set [DATE] also indicated that Resident #104 required assistance with most aspects of his/her activities of daily living. Review of the clinical record indicated that Resident #104 was seen on 5/20/19 by his/her primary care physician and an order was written to obtain a gynecological consult due to complaints of vaginal pain. Review of the clinical record failed to indicate that Resident #104 had a gynecological consult after 5/20/19. During an interview on 6/14/19 at 8:55 A.M., Resident #104 said that he/she has had vaginal pain for about a month that comes on when he/she gets out of bed into the wheelchair. Resident #104 said that he/she was supposed to see a gynecologist, but had not. During an interview on 6/17/19 at 1:48 P.M., Unit Manager #1 said that she checked the appointment book and that an appointment was never made for the Resident #104 to see the gynecologist. Resident #104's medical treatment has been delayed due to the failure to book gynecological appointment, 28 days after the order for a consult was obtained.

Based on interviews and records reviewed, for one out of three sampled residents (Resident #1), the Facility failed to provide adequate safety measures to prevent falls, when on 6/4/17, Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was on an air mattress (for wound healing), without another staff member present, resulting in Resident #1 sustaining a fall from his/her bed onto the floor. Resident #1 was transferred to the emergency room , where he/she was diagnosed with [REDACTED]. Findings include: The policy titled Alternative Mattresses, dated 1/2012, indicated residents requiring alternative support surfaces would also require two care giver assist while providing care in bed. Resident #1 was admitted to the facility on [DATE], and his/her [DIAGNOSES REDACTED]. Review of Resident #1's medication orders, dated 6/1/17, indicated Resident #1 was prescribed Eliquis (anticoagulant), which can cause increased bleeding. A Care Plan, undated, indicated Resident #1 required an alternative support mattress for wound healing, repositioning every two hours, and was at risk for falls. A Resident Care Card, undated, indicated Resident #1 required extensive physical assist of two staff members for bed mobility and positioning. A Nurse Progress Note, dated 6/4/17, timed 8:52 A.M. indicated Resident #1 sustained a fall on to the floor from his/her bed while receiving care from Certified Nurse Aide (CNA) #1 at 6:40 A.M. was bleeding from a cut on the back of his/her head, was complaining of severe back pain, and was transferred to the emergency room for evaluation. An emergency room note, dated 6/4/17, indicated Resident #1 was admitted to the hospital with [REDACTED]. The Surveyor interviewed Nurse #1 at 1:40 P.M. on 8/1/17. Nurse #1 said that on 6/4/17 around 6:30 A.M. CNA #1 was changing Resident #1 in bed, and she asked CNA #2 to go help CNA #1. Nurse #1 said a few moments later, she was told Resident #1 was on the floor, and when she arrived at Resident #1's room, Resident #1 was on the floor, lying parallel to and halfway under the bed, was bleeding from a cut on the back of his/her head, and was complaining of severe back pain. Nurse #1 said Resident #1 was transferred to the emergency room for evaluation. The Surveyor interviewed CNA #1 at 11:52 A.M. on 8/1/17. CNA #1 said that on 6/4/17, during last rounds on the 11 P.M. to 7:00 A.M. shift she tried to provide care to Resident #1. CNA #1 said Resident #1 was on an alternative mattress, was helpless, and could not hold on to anything due to contractures, or words to that effect. CNA #1 said she provided care to Resident #1 by herself, and when she tried to roll Resident #1, he/she slid off the opposite side of the bed and onto the floor. CNA #1 said the shape of the air mattress made it easy for Resident #1 to roll off the side of the bed. CNA #1 said she did not ask for help, but she should have had someone there to help her. The Surveyor interviewed the Director of Nurses at 8:35 A.M. on 8/1/17. The Director of Nurses said any resident on an alternative mattress requires two staff members for bed mobility/care, because the shape of the bed could cause someone to roll off the bed.

Based on record review and interviews, the facility failed to ensure that 1 resident (#27) in a total sample of 30, who displayed mental or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem. For Resident #27, the facility failed to ensure a psychiatric consult was obtained as ordered by his/her physician. The resident's behaviors escalated over an 18 day period which ended with the resident being transferred to the hospital due to behavioral outbursts. Findings include: Resident #27 was admitted to the facility in 12/2013 after a psychiatric hospitalization with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, dated 12/17/13, indicated that Resident #27 was cognitively intact, exhibited verbal behaviors such as yelling out and wandering behaviors that impacted others. On 3/26/14 at 10:00 A.M., review of the resident's clinical record indicated the resident had a 12/11/13 physician's orders [REDACTED]. Review of the Physician's progress note indicated the following: *12/12/13- resident had a difficult night, experiencing increased agitation, will get psych to follow up. *12/16/13- resident eloped, was agitated when he was found, brought back, will go Arborwood (a secure unit within the facility) for psych care. Review of the Resident's interim plan of care, not dated, for Potential Alteration in Psychosocial /Mood/Behavior/Well-being indicated the following: * Monitor behaviors every shift. * Medications as ordered. Review of a Behavior Care Plan, dated 12/16/13, indicated the following: Problem: At risk for elopement as evidenced by resident left the faciity on [DATE]. Goal: Resident will not leave facility unattended, safety will be maintained and resident will demonstrate acceptance of daily routine. Approach: Assess causes and effectiveness of interventions, assess for fall risk, distract Resident from wandering, document all incidents of wandering, identification on resident, maintain safety at all times, make sure all staff are aware of elopement risk and make sure Wanderguard (monitoring device worn around wrist to alert staff that resident is leaving a specific part of the facility) is on at all times. No where within the Behavior care plan did the facility address the resident's yelling out and striking out behavior. During interview on 3/26/14 at 11:00 A.M., the Director of Social Work (DSW) said that the facility uses a specific company to provide mental health services and that the psychiatrist comes every Monday. There are also two mental health workers (she was not sure of their credentials) that combined, provide coverage Monday through Friday in the facility. The DSW was not aware if Resident #27 had been seen by the psych team, but acknowledged that the resident had a history of [REDACTED]. Review of the Resident Progress Notes indicated the following: * 12/12/13 3:38 P.M., Nursing entry- patient not compliant sitting on wheelchair, he/she kept getting up, was redirected. [MEDICATION NAME] (for Mood disorders) was given to patient for agitation and patient safety maintained (Although the psych staff were in the facility, the resident was not seen as ordered). *12/13/13 2:42 P.M., Nursing entry- Agitation noted this shift, refused prn (as needed) [MEDICATION NAME] (antipsychotic medication) (although the psych staff were in the facility, the resident was not seen as ordered). *12/14/13 10:41 P.M., Nursing entry-patient has intermittent of agitation and calmed, [MEDICATION NAME] and [MEDICATION NAME] was given with good effect. Pateint refused to use wheelchair and refused therapy. *12/15/13 3:37 P.M., Nursing entry-patient was given [MEDICATION NAME] at 1:00 P.M. for agitation. Patient refused therapy and to use wheelchair or walker for safety. *12/16/13 4:20 P.M., Nursing entry-patient went to smoke area at 9:00 A.M., at 11:00 AM. staff went to patient room, he/she wasn't there, then at 11:15 A.M. staff went to smoke area, he/she wasn't there. Search found patient walking up the street with a shopping bag. Patient refused to come back to facility. Staff called 911 and patient was transported to hospital for evaluation (although the psych staff were in the facility, the resident was not seen as ordered). *12/16/13 6:30 P.M., Social Worker entry- Resident was found to have left facility, once found, was transferred to hospital and returned to facility the same evening. Family member expressed concerns for resident's safety and well being. *12/17/13 12:15 A.M., Nursing entry-verbally abusive, refused to be assessed by nurse. *12/27/13 2:37 P.M., Nursing entry-patient is noncompliant with meds. Patient stated "I know my rights, no one can force me" continue to monitor (although the psych staff were in the facility, the resident was not seen as ordered). *12/27/13 3:35 P.M., Social worker entry- resident has been exhibiting increased delusional thinking and paranoia. His/her mood has been labile, ranging from, [MEDICAL CONDITION] flat effect, to tearful. There was a discussion with the resident, Director of Nursing, Unit Manager and Social Worker. Resident ended the discussion walking away angrily. The Physician was called and ordered a prn dose of [MEDICATION NAME] (antipsychotic medication), feeling like he did not require hospitalization at this time. *12/29/13 3:36 P.M., Nursing entry- resident alert, confused and agitated, at 7:00 A.M. he/she was trying to leave the facility, screaming that his/her food was cold, he/she refused medications, at lunch time he/she came out of his/her room screaming and kicking because of the type of food served to him/her. Staff notified the physician, who cleared the resident to be transferred to the hospital for a psych evaluation. Staff from the facility called ambulance and asked for police assistance because the patient was hitting everything in front of him/her and using his/her walker as a weapon. Patient agreed to go to the hospital. *1/10/14 4:15 P.M., Social Worker entry- resident was discharged to the hospital as of 1/8/14. During interview on 3/26/14 at 1:50 P.M., the DON said that he called the psych team to see if they had seen Resident #27 while he/she was in the facility. He confirmed that the resident had not been seen, despite his/her behaviors and a physician's orders [REDACTED]. From 12/11/13 when the physician ordered a psych consult to 12/29/13 when the resident's behaviors escalated to the point that this resident was transferred to the hospital, and was never seen for a psych consult.

Based on observation, record review, and interviews, the facility failed for 1 sampled resident (#26) of 5 applicable residents with pressure sores, out of a total sample of 30 residents, to keep the resident from developing a pressure sore. The facility also failed to ensure that necessary treatment and services were provided to promote healing. Findings include: For Resident #26, the facility failed to ensure that the resident received effective, preventive interventions that would relieve pressure to the resident's heel, in order to prevent the development of a pressure area. The facility also failed to provide timely treatment to prevent the worsening of a pressure ulcer. Resident #26 developed a stage two pressure ulcer (3 centimeter (cm) by 3 cm blister) to his/her right heel which progressed to a stage three pressure ulcer requiring treatment with a topical [MEDICATION NAME] agent (removes non-viable tissue). Review of the resident's clinical record on 03/26/14, indicated that the resident was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. The resident has since been transferred to another skilled facility. Review of the resident's admission Minimum Data Set Assessment (MDS), dated [DATE], indicated that the resident required extensive assistance for bed mobility and transfers. He/she was non ambulatory. The MDS coded the resident as having no pressure ulcers. A "Nursing Admission Assessment" completed on 11/19/13, indicated no red or open areas to either heel, and identified the resident as being high risk for skin breakdown. Review of the facility's "Wound Care Protocol", dated 2013, included the following: * A skin assessment will be done on all new admissions and weekly thereafter. The information gathered from the skin assessment will be used to develop the resident's interim plan of care and will be communicated to the interdisciplinary team and incorporated into the resident plan of care. * Norton Plus Skin Assessment Scale will be done for new admissions by day 14 and at least quarterly. * Weekly documentation of pressure ulcers will include: site/location, stage, measurements, progress in healing. Review of the interim care plan, dated 11/19/13, for Actual or Potential Alteration in Skin Integrity indicated the resident had a Norton Plus Skin Assessment score of 8 (indicating resident was at high risk for skin breakdown) and indicated the following: * Reposition every 2 hours and as necessary. * Monitor signs and symptoms of infection. * Report changes immediately. Review of the Resident Care Card (used by the Certified Nurses Aides to provide care), which was not dated, indicated several areas of care to be provided via a "check off" and/or "circling" system included: * Prevention Devices which included heel protectors and elbow protectors- neither were checked off. * Postioning Devices which included various cushions, wedges and bolsters, none were checked off. * Decubitus Prevention which included heel protectors, elbow protectors and [MEDICATION NAME] cream (a protective skin cream) none were circled. Despite the resident being identified as high risk for skin breakdown, the Resident Care Card did not identify preventative measures for this resident. Review of an orthopedic referral form dated 12/6/13, indicated a recommendation from the orthopedic surgeon to "provide local wound care to the right heel". Review of the "Physician's New Orders" sheet, dated 12/6/13, indicated the following: Apply Prevalon boots (relieves pressure to the heels) to both lower extremities at all times and apply Skin Cote (provides protective coating to skin to aid in preventing skin breakdown) to right heel every shift. Despite the recommendation from the orthopedic physician and the new physician orders on 12/6/14; there was no evidence within the clinical record to explain why a treatment was necessary to the right heel. Review of the "Treatment Administration History" form, dated 11/19/13 -12/19/13, indicated the following treatments: * 12/8/13- Prevalon Boots to both lower extremities at all times, dated 12/8/13, but not initialed by a licensed nurse as being implemented until the 7:00 A.M -3:00 P.M. shift on 12/11/13. * 12/8/13- Skin Cote to right heel every shift, dated 12/8/13, but not initialed by a licensed nurse as being implemented until the 7:00 A.M.- 3:00 P.M. shift on 12/11/13. Despite the 12/6/13 physician orders for the Prevalon boots and Skin Cote, the orders were not implemented until 12/11/13, 5 days later. Review of the Nursing Progress Notes indicated the progression of the pressure ulcer as follows: * 12/10/13- Right heel fluid filled blister, 3 cm by 3 cm in diameter. The facility did not stage the blister per the facility's wound care protocols. This note was completed 4 days after the physician's orders to begin wound treatment to the right heel were ordered. * 12/16/13- Right heel blister open 4.5 cm by 7 cm beefy red, small sero-sanguinous (clear-bloody) drainage. The stage of the wound was not documented in the clinical record. * 12/19/13- Right heel open blister, 80% viable tissue, 20% non-viable tissue. Recommend Santyl (chemical [MEDICATION NAME] medication) to non-viable (yellow) tissue daily. * 12/25/13- Right heel wound dressing changed, open area red, moist tissue with slough at the center, moderate serous drainage, no odor. On 12/26/13 the facility asked the Wound Physician to provide a consult in regard to Resident #26's right heel pressure ulcer. Review of the "Wound Care Specialist Initial Evaluation" form, dated 12/26/13, described the wound as follows: * Stage 3 pressure wound to the right heel with moderate sero-sanguinous drainage. * Wound size : 3.0 cm by 6.0 cm by 0.2 cm depth. * 10 % thick adherent devitalized necrotic tissue. * 90 % granulation tissue. During interview, on 3/26/14 at 1:00 P.M., the facility wound nurse said that she did not know why there were orders obtained on 12/6/13 to treat the right heel, she said the heel was probably boggy, but she didn't know for sure. When asked by the surveyor why the physician orders for wound care were not implemented until 12/11/13, she said she did not have an answer to that, but that maybe another nurse from that unit could answer that question. The surveyor asked to have any nurses the facility felt could explain this issue, be brought to the surveyor. No other nurses were brought for interview. During interview on 3/26/14 at 2:00 P.M., the surveyor reviewed Resident #26's treatment sheets with the Director of Nursing (DON) who said he did not know why the wound care orders obtained on 12/6/13 were not implemented until 12/10/13. He said he would investigate the matter. He also confirmed that the Resident Care Card was incomplete and did not identify the preventative measures that should have been in place for Resident# 26.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received the correct medication as ordered by the physician. On 1/25/14, at approximately 10:00 A.M., Nurse #1 administered Resident #1 another resident's medication: [MEDICATION NAME] sulfate (an opioid [MEDICATION NAME]). At approximately 12:00 P.M. Resident #1 became very lethargic, the Nurse Practitioner (NP) was notified and ordered Resident #1 transferred to the Hospital for evaluation. Findings include: The Resident Administration Record dated February, 1993, indicated that Resident #1 was admitted to the Facility with [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 12/27/13, indicated that Resident #1 had intact cognition. The nurse's note, dated 1/25/14, written at 2:01 P.M., indicated that Resident #1 appeared weak and was assisted back to bed after breakfast. The nurse's note indicated that Resident #1's blood pressure was 108/73, heart rate 88 beeps per minute, and he/she had a blood oxygen saturation level of 89% on room air and Nurse #1 administered oxygen at two liters per minute via nasal cannula. The nurse's note indicated that Resident #1 had no previous history of respiratory illness. The nurse's note indicated that Resident #1's blood oxygen saturation level increased to 93%, and he/she continued to be more lethargic. The nurse's note indicated that Nurse #1 notified the Nurse Practitioner (NP) and she ordered Resident #1 be transferred to the Hospital for evaluation. The Surveyor interviewed Physician #1 at 2:45 P.M. on 2/6/14 and at 3:30 P.M. on 2/20/14. Physician #1 said on 1/25/14 he received an email (time unknown) from the NP that indicated Resident #1 had a change in condition that included lethargy and change in mental status. Physician #1 said the NP indicated that she gave an order to transfer Resident #1 to the Hospital for evaluation. Physician #1 said the next day he received an email from the Facility Administrator that indicated Resident #1's urine tested positive for opioid. Physician #1 said he questioned opioids in Resident #1's urine and encouraged the Facility to conduct an internal investigation. Physician #1 said he believed that Resident #1 experienced a change of condition as a result of the dose of [MEDICATION NAME] sulfate that he/she received in error. Physician #1 said it could take up to thirty minutes for someone to experience respiratory distress after receiving [MEDICATION NAME] sulfate. The Surveyor interviewed the Director of Nurses (DON) at 10:00 A.M. on 2/6/14. The DON said Nurse #1 was terminated due to the medication error. The DON said Nurse #1 admitted she administered another resident's medication to Resident #1 on 1/25/14. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 2/6/14 and at 4:50 P.M. on 2/19/14. Nurse #1 said at approximately 9:30 A.M. on 1/25/14, Resident #2 appeared at the medication cart and requested his/her [MEDICATION NAME] sulfate. Nurse #1 said she poured the [MEDICATION NAME] sulfate 30 milligrams (mg), added applesauce to the medication cup, but did not administer it because Resident #2 refused to take the pill with applesauce. Nurse #1 said she stored the medication cup in the top drawer of the medication cart, to be discarded later with another nurse. Nurse #1 said she poured another [MEDICATION NAME] sulfate 30mg and administered it to Resident #2. Nurse #1 said after pouring Resident #1's medications, she heard Nurse #2 and a Certified Nurse Aide (CNA) yelling for help, and saying one of Nurse #1's residents was in the elevator. Nurse #1 said she immediately stored Resident #1's medication in the top drawer of the medication cart and went to help with the resident. Nurse #1 said upon returning to the medication cart she accidentally took the cup that contained the [MEDICATION NAME] sulfate and administered it to Resident #1. Nurse #1 said at approximately 11:00 A.M. Resident #1 had a change in condition, appeared drowsy and had a blood oxygen saturation level that dropped to 89%. Nurse #1 said she administered oxygen at 2 liters per minute via nasal cannula to Resident #1 with some effect. Nurse #1 said at approximately 12:00 P.M. Resident #1 became very lethargic. Nurse #1 said she notified the NP on call and obtained an order to transfer Resident #1 to the Hospital for evaluation. The Surveyor interviewed Nurse #2 at 3:42 P.M. on 2/19/14. Nurse #2 said she believed that Nurse #1 might have stored Resident #1's medication in the top drawer. Nurse #2 said when she yelled for help with the resident that was in the elevator, Nurse # 1 was dispensing medications and stopped to help. Resident #1 said he/she did not recall the medication incident. The Hospital Discharge Summary dated 1/29/14, indicated that Resident #1's laboratory report dated 1/25/14 indicated that Resident #1 had opiates and benzodiazepines (Resident #1 had an MD order for [MEDICATION NAME], an antianxiey medication) in his/her urine. The Hospital Discharge Summary indicated Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 responded to [MEDICATION NAME] and was admitted to the Intensive Care Unit (ICU) on a [MEDICATION NAME] drip.

Based on record review, and staff interviews, the facility failed to ensure that 6 of 12 residents who fell ( #1, #9, #11, #17, #19 and #21) in a total sample of 24, were provided adequate supervision and effective interventions to prevent accidents. Findings include: 1) For Resident #17, the facility failed to provide effective interventions and devices to avoid falls. The Resident had 5 falls out of his/her wheelchair, with 1 fall resulting in a fractured rib. Resident #17 was admitted to the facility on [DATE] and readmitted January 2013 with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS), dated [DATE], identified the Resident's cognition as severely impaired, and an extensive physical assist with 1 staff person for all transfers. The MDS identified the Resident as a limited assist of 1 staff person for hygiene, however an extensive assist of 1 staff person for bathing. The Resident was identified as being continent of bowel and bladder A falls care plan, initiated on 5/12/11, indicated that the Resident was at risk for falls and injury related to syncope, difficulty walking, and the use of psychotropic medications. The care plan include the following interventions: - Call light within reach. - Remind to use call light for any assistance. - Maintain a safe and clutter free environment. - Keep room well lit at night. - Provide proper footwear. - Ambulates with 1 assist. - Assist with transfers and ambulation. - Encourage attendance at activities that minimize fall potential while meeting need to socialize - Rehab screen -- educate - Rehab screen ---- ? reacher - Sent to hospital upon return patient patient on physical therapy and occupational therapy for balance and transfer - self propel wheelchair independently on the unit - needs assist when in wheelchair and off the unit Record review of the Resident's clinical record indicated the following falls and incidents: Fall/Incident #1 Review of the Resident-Visitor Incident/Accident Report indicated that on 4/1/12 at 12:00 P.M., the Resident, who was in his/her room, stood up from his/her wheelchair to reach in the clothing closet. The Resident lost his/her balance and landed on his/her buttocks. The plan to prevent reoccurrence was for the Resident to have a rehabilitation screen and the care plan was not updated after this recent fall. However, a rehabilitation screen was not in the resident's clinical chart at the time of the survey. Fall/Incident #2 Review of the Resident-Visitor Incident/Accident Report on 10/13/12 at 10:00 A.M., indicated the Resident was found on the floor in the bathroom. The initial assessment indicated that the Resident was transferring his/herself from the wheelchair to the toilet and the wheelchair was unlocked. The plan to prevent reoccurrence was for the Resident to have a Rehabilitation screen. A nursing note, dated 10/13/12, stated that the Resident was found on the bathroom floor. The Rehabiltiation Screening/Communication form, dated 10/16/12, indicated that the Resident was found on the floor in the bathroom. The Resident was currently at his/her functional baseline of requiring close supervision for transfers, secondary to poor safety awareness. No skilled services required at that time, and the care plan was not updated. Fall/Incident #3 Review of the Resident-Visitor Incident/Accident Report indicated on 12/16/12 at 11:00 A.M., the Resident was found, by staff, sitting on the bathroom floor. The Resident apparently slid off the wheelchair while attempting to reach for a bracelet. The Resident was found naked, with his/her johnny and sneakers lying on the floor. The report revealed that a licensed staff stated, "I heard the Resident asking for help". The nurse went into the Resident's room and found the Resident sitting on the bathroom floor, naked, and his/her clothes were beside him/her, including the jewelry. The plan to prevent further reoccurrence was to have a Rehab screen However, the was no documentation in the nursing notes that a fall had occurred. The Rehabilitation/Communication form, dated 12/20/12, indicated that physically the Resident was at his/her functional baseline, requiring physical assist with all transfers. The staff were to remind the Resident to ask for assist with transfers (this intervention would have been ineffective due to the resident being severely impaired in cognition). No skilled physical therapy needed at this time, and the care plan had not been updated with interventions to prevent further falls of this type. Fall/Incident #4 Review of the Resident-Visitor Incident/Accident Report indicated on 1/25/13 at 4:30 P.M., the Resident was attempting to reach for the window blind to open it, lost his/her balance and fell out of the chair. The plan to prevent this incident from reoccurring was to have a rehabilitation screen upon the Resident's return from the hospital. A nursing note, dated 1/25/13, indicated that the Resident had fallen around 4:30 P.M.. The note stated that the Resident reported that he/she was trying to stand to close the curtain, then fell backwards onto the chair. The Resident was discovered by Unit Manager #1, to be sitting halfway on his/her wheelchair. The Resident complained of pain on his/her right lateral rib. The Resident was sent out to the hospital for further evaluation, and found to have left lobe pneumonia and a 9th right lateral rib fracture, nondisplaced. The Rehabilitation/Communicate form, dated 2/1/13, indicated that the Resident was evaluated and will be seen by occupational therapy for pain management and transfer training. There were no new interventions noted on the Resident's care plan to prevent further falls. Fall/Incident #5 Review of the Resident-Visitor Incident/Accident Report on 2/6/13 at 9:30 A.M., indicated the Resident was found on the floor in his/her bedroom, beside his/her bed. The Resident stated that he/she wanted to get up from the wheelchair and attempted to transfer self and fell . The plan to prevent reoccurrence was to have a rehabilitation screen, which resulted in the facility needing to keep the Resident in a supervised area for safety. However, there was no update to the Resident's care plan indicating that the Resident needed to be in a supervised area for safety. Observations on 2/6/13 at 11:15 A.M., 1:45 P.M. and 4:10P.M., revealed that the Resident was alone in his/her bedroom in his/her wheelchair. Observations on 2/7/13 at 9:45 A.M., 1:30 P.M. and 4:40 P.M., revealed that the Resident was sitting alone in his/her bedroom, rummaging through a dresser drawer while sitting in his/her wheelchair. There was no supervision during these observed times. During an interview with Unit Manager #1 on 2/7/13 at 2:15, Unit Manager #1 stated that she was unaware that there was a recommendation from rehab to keep the Resident in a supervised area for safety. The facility failed to provide proper supervision to this Resident who sustained injuries and failed to develop proper interventions to keep the Resident safe from further falls. 2). For Resident #9 the facility failed to provide effective interventions and devices to avoid falls. The Resident had 5 falls out of his/her wheelchair, with 1 injury resulting in a laceration to the right side of his/her forehead. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The falls care plan, dated dated 9/10/11 and updated 9/4/12 for the annual review, indicated that the Resident was at high risk for falls related to the following: having a history of falls, balance problems, poor safety awareness, incontinence, and daily use of psychotropic medications. The interventions that had been put into place were as follows: - call light within Resident's reach - remind the Resident to use the call light - verbal cues for safety - maintain a safe and clutter free environment - keep rooms well lit at night - keep all needed items near the Resident for easy accessibility - safety checks as needed - OT/PT consult as needed - respond to call lights promptly - fall risk assessment quarterly and with change in status - transfer with one assist - walks with walker with one assist - incontinence care promptly - rehab screen An annual MDS, dated [DATE], identified the Resident's cognition as severely impaired, and rarely never understands. The MDS identified the Resident as requiring extensive assist with all activities of daily living, and requires extensive assist with 1 staff for all transfers. Record review revealed that the Resident had 5 falls, with 1 unwitnessed fall resulting in a laceration to the forehead. Fall/Incident #1 Review of the Resident-Visitor Incident/Accident Report indicated on 3/21/12 at 6:50 P.M., the Resident had lost her strength as he/she attempted to get up out of the chair, and slid to the floor. The plan to prevent reoccurrence was to have a rehabilitation screen, which recommended to continue to follow the current fall plan of care. The Resident's care plan had not been updated with further interventions to prevent falls. A Rehabilitation screen, dated 4/12/12, indicated that the Resident had fallen attempting to transfers him/her self. The report noted that the Resident was at her/his functional baseline due to having dementia and the inability to follow simple directions for an exercise program. The Resident continued to require close supervision for ambulation and transfers. Fall/Incident #2 Review of the Resident-Visitor Incident/Accident Report indicated on 5/1/12 at 7:00 A.M., the Resident was found on the floor in the bathroom. The Resident apparently lost his/her balance while in the bathroom and sustained a laceration to the right side of the his/her forehead. The Resident was unable to recall what had happened due to his/her dementia. A nursing note, dated 5/1/12, indicated that the Resident was found on the floor bleeding from a laceration to the right side of the forehead. The care provided prior to hospitalization was to medicate for complaints of pain and ice held on the wound to stop the bleeding. On the Incident/Accident Report, dated 5/1/12, the Unit Manager #1 noted that the Resident apparently got out of bed and went into the bathroom where he/she lost his/her balance and fell . The Resident was then transferred to the hospital for further evaluation. The 5/1/12 Incident/Accident Report noted that nursing heard a loud thump and ran to the Resident's room where they found him/her on the floor bleeding from a laceration on the right side of his/her forehead. Review of the Resident's clinical record revealed a hospital discharge summary, dated 5/1/12, which indicated that the Resident's injuries, from the recent unwitnessed fall, as a paranchymal hemorrhage in the right frontal lobe measuring approximately 2 x 1 x 2.2 centimeters, and smaller discontiguous areas of hemorrhage in the left frontal lobe. The report indicated that the plan to prevent reoccurrence was to have a rehabilitation screen once the Resident returned from the hospital. There was no further updates to the Resident's care plan. A Rehabilitation Screen, dated 5/3/12, indicated that the Resident required assist and was at baseline secondary to [DIAGNOSES REDACTED]. Fall/Incident #3 Review of the Resident-Visitor Incident/Accident Report indicated on 5/15/12 at 3:00 P.M., the Resident was sitting across from the nurse's station and as he/she got up from the chair to ambulate, he/she had lost his/her balance and slid to the floor. The plan to prevent reoccurrence was to have a rehabilitation screen. There was no further care plan interventions put in to place at that time to prevent further falls. A Rehabilitation screen, dated 5/18/12, noted that the resident has dementia and poor safety awareness, and requires assist for activities of daily living and mobility. The report noted that nursing will continue to supervise the Resident for safety awareness. A quarterly falls assessment, dated 6/8/12, noted that the resident scored a 15, which was a high risk for falls. Fall/Incident #4 Review of the Resident-Visitor Incident/Accident Report indicated on 6/29/12 at 2:00 P.M., the Resident was ambulating on the unit, lost his/her balance and fell . In the report, the nursing staff stated that the Resident was standing up in front of his/her room holding onto his/her walker. The Resident removed his/her hand from the walker, lost his/her balance and fell on his/her buttocks. The report indicated that the plan to prevent re-occurrence was to have a Rehabiltiation screen done. There were no further care plan interventions put in place at that time to prevent further falls. A Rehabilitation screen, dated 7/10/12, noted that the Resident requires supervision for ambulation and was at baseline secondary to reduced safety awareness. No further skilled interventions were indicated. A quarterly falls assessment, dated 9/18/12, noted that the resident scored a 14, which was a high risk for falls. Fall/Incident #5 Review of the Resident-Visitor Incident/Accident Report indicated on 12/1/12 at 3:00 P.M., the Resident was in the dayroom and needed to be toileted. The nurse's aide walked the Resident to his/her room and sat him/her down in a chair beside the bedroom entrance. The nurse's aide left the Resident alone in his/her room, and went to get a incontinence brief from the utility room. The nurse's aide stated that when she returned, the aide observed that the Resident had walked over to his/her bed, and had fallen on the floor. The nurse's aide stated that there were no other aides around at this time. The Unit Manager stated in the report, "the Resident got up from chair where he/she was put, while the nurse's aide went for an incontinence brief to change the Resident". The Resident lost his/her balance and landed on his/her buttocks. The plan to prevent reoccurrence was to have a rehabilitation screen. There was no further care plan interventions put in place at that time to prevent further falls. A quarterly falls assessment, dated 12/3/12, noted that the Resident scored a 16, which was a high risk for falls. A Rehabilitation screen, dated 12/5/12, noted that the Resident was now on Hospice, and was toileting with a nurse's aide when he/she lost his/her balance and fell . It was noted that no further skilled interventions were indicated. In an interview with the Unit Manager #1 on 2/5/13 at 3:00 P.M., She said that she was not aware that the Resident may have issues regarding being left unattended, or required any type of supervision even though the Resident was assessed as a high risk for falls. The facility failed to provide proper supervision to this Resident who sustained injuries and failed to develop proper interventions to keep the Resident safe from further falls. 3). For Resident #21, the facility failed to provide effective interventions and devices to prevent falls. The Resident had 2 falls out of his/her wheelchair, with 1 injury resulting in a nasal fracture and an abrasion on the bridge of his/her nose. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that the Resident had 2 falls, which 1 fall was with an injury (nasal fracture). Fall/Incident #1 Review of the Resident-Visitor Incident/Accident Report indicated on 1/28/13 at 5:15 A.M., the Resident was found on the bedroom floor while attempting to get up from his/her wheelchair. The report noted that the Resident lost his/her balance and had fallen on his/her back. No injuries noted. A plan to prevent a reoccurrence was to have a rehabilitation screen. A Rehabilitation/Screening/Communication Report, dated 2/2/13, noted that the Resident was receiving physical therapy, and recommended that the Resident use his/her rolling walker when supervised by nursing and/or rehab staff. The Resident has a wheelchair for mobility on the unit. Fall/Incident #2 Review of the Resident-Visitor Incident/Accident Report indicated on 1/30/13 at 2:30 P.M., the Resident approached the nurse's station and reported that he/she fell face down in his/her room. The report noted that the Resident had an abrasion on his/her nose. An initial fall assessment, dated 1/30/13, noted that the Resident scored a 19, which made him/her a high risk for falls. A Rehabilitation/Screening/Communication Report stated that the Resident had a fall, which resulted in a nasal bone fracture. The Resident was currently on physical therapy. Recommendations were that the Resident has a wheelchair for mobility on the unit, and should be encouraged to ambulate with rehab and/or nursing staff for safety. An initial falls care plan, developed on 2/2/13, identified preliminary concerns for the Resident who was at risk for falls related to balance issues, cardiovascular [DIAGNOSES REDACTED]. The Resident's goal was to not sustain any injury from falls, and the interventions are as follows: - call light within resident's reach - remind to use call light - verbal cues for safety - maintain a safe and clutter free environment - keep room well lit at night - keep all items near for easy accessibility - OT/PT consult as needed - safety checks as needed - respond to call lights promptly - fall risk assessment quartely and if change in status - discourage the Resident from getting up unassisted if feeling dizzy, drowsy, and/or not fully alert - assist the Resident with transfers and ambulation - encourage the Resident to use a walker - Rehab screen (physical and occupational therapy) Throughout the survey, on 2/5/13 (from 8:00 A.M. to 11:50 A.M and 1:00 P.M. to 5:00 P.M.), on 2/6/13 ( from 7:30 A.M. to 3:00 P.M.), and on 2/7/13 (from 1:30 P.M. to 3:30 P.M.), the Resident was observed by the surveyor, walking around the unit independently and unsupervised, and at times without using his/her rolling walker. At no time did the Resident use his/her wheelchair for mobility on the unit. An interview was conducted with the Unit Manager #1 on 2/7/13 at 2:25 P.M., she said that she was unaware of the physical therapy recommendation; to encourage the Resident to ambulate with staff for safety, and requires the use of a rolling walker at all times. The facility failed to provide proper supervision to this Resident who sustained major injuries, and failed to develop proper interventions to keep the Resident safe from further falls. On 2/25/13, Resident #21 had 1 unwitnessed fall with complaints of left side rib pain. Review of the Resident's clinical record, on 2/25/13, noted the following: A nursing note, dated 2/9/13 (during the 7:00 A.M. to 3:00 P.M. shift) revealed that the Resident was found on the bathroom floor, and the Resident was complaining about left side rib pain. The physician was notified and a new order was for left rib X-rays to rule out a fracture. A nursing note, dated 2/10/13, indicated that the X-rays were negative for any fractures related to the Resident's fall. An Incident/Accident report, dated 2/9/13 at 10:30 A.M., indicated that the Resident was found on the floor in the bathroom. The Resident stated that he/she was trying to go to the bathroom, lost his/her balance and fell . The Resident had complaints of pain to his/her left rib area. The report noted that the falls care plan was revised due to the recent 2/9/13 fall to include a urinary analysis with culture sensitivity and a bowel and bladder diary was to be initiated. The report noted that the Resident's pain was treated and X-rays were to be done per the physician's orders [REDACTED]. a walker. The facility failed to provide proper supervision to this Resident who sustained major injuries with previous falls, and failed to develop proper interventions to keep the Resident safe from further falls. 4. For Resident #19, the facility failed to provide adequate supervision and effective interventions to prevent repeated falls. On 2/6/13 at 10:15 A.M., review of the resident's clinical record indicated the resident was admitted to the facility in 7/08, with [DIAGNOSES REDACTED]. Resident #19 sustained a total of 7 falls from July 2012 through February 2013, with the most recent fall resulting in a skin tear on the right knee and right elbow and a bruise to the right forehead. The resident had a history of [REDACTED]. The resident's most recent MDS significant change assessment dated [DATE], indicated the resident required extensive assistance with activities of daily living, was independent with eating and was totally incontinent of bladder and bowel. The MDS also indicated that the resident coded a 10 out of 15 for Section C, Brief Interview for Mental Staus, which indicated the resident had some cognitive impairment. A care plan for "risk for falls and a history of falls" dated 7/18/12, had the following interventions: Call light within resident's reach Remind to use call light for any assistance Place bed in lowest position Attend toileting needs promptly Fall risk assessment quarterly Slipper sock at all times Encourage attendance at activities Rehab screen (updated on care plan after 7/18/12 fall, 8/31/12 fall , 9/2/12 fall , 12/25/12 fall and 2/3/13 fall) Bed alarm (update after 7/18/12 fall) Chair alarm clip (update after 8/19/12 fall) The facility's incident/accident reports, incident/accident follow-up reports, nursing notes and rehabilitation screenings indicated the following: The incident/accident report dated 7/18/12, indicated that on 7/18/12 at 3:20 P.M., the resident was found on the floor in his/her bed room. The resident had gone to the closet to get clothing and fell . The resident was barefoot at the time of the fall. The incident/accident report indicated the resident was non-compliant with wearing proper footwear and the resident refused to wear slipper socks. The resident will be encouraged to wear proper footwear. According to the incident/accident report, nursing assessed the resident and documented that the resident had pain and swelling of the right wrist. The resident's physician was notified and ordered an X-ray. The X-ray indicated a right wrist fracture. The physician was notified and ordered the resident be sent to the hospital. The resident returned from the hospital with a splint on the right arm. The incident/accident follow- up report dated 7/18/12, indicated the update to the resident's plan of care was a rehabilitation screen and a bed alarm. The rehabilitation screen dated 7/19/12, indicated the resident was to focus on safety. The care plan was updated with a bed alarm, however, no new interventions were put in place to address the resident's non-compliance with wearing the proper footwear. On 8/19/12 at 8:00 P.M., the resident was found on floor in his/her bedroom. According to the nursing note, the resident said, "I got up, I know I am not suppose to, but I did." The resident tried to transfer from the wheelchair to the bed by him/herself. The resident hit her/his head and sustained a skin tear to the left elbow. The physician was notified and ordered the resident to be sent the hospital for further evaluation. The resident returned to the facility with no new orders. The incident/accident follow-up report dated 8/19/12, indicated that the resident would utilize a chair clip alarm. The resident's care plan was updated with the chair clip alarm. On 8/31/12 at 4:30 P.M., the resident was found on the floor. The resident said "He/she was trying to fix the bed spread and fell ". The resident sustained [REDACTED]. The incident/accident follow-up report dated, 8/31/12, indicated a rehabilitation screen would be completed. The rehabilitation screen was added to the care plan as a new intervention. No other new interventions were implemented. On 9/2/12 at 7:00 P.M., the resident was found in a bathroom in the hallway on the unit after toileting his/herself. The resident was found on their knees. The resident did not sustain any injuries. According to the nursing note, the resident was redirected to call for help, but the resident told nursing that she/he does not want to be helped to the bathroom. The incident/accident follow-up report dated 9/2/12, indicated a rehabilitation screen would be completed. According to the rehabilitation screen dated 9/4/12 (regarding the 8/31/12 and 9/2/12 fall), the resident continued to be a fall risk due to the resident's decrease in cognition and impulsive behavior and recommended using an alarmed seat belt. This new intervention was not implemented. On 9/8/12 at 10:00 A. M, the resident was found in the bathroom on the floor between the toilet and the resident's wheelchair. The resident stated that he/she had used the toilet, tried to get back into the wheelchair, slipped and fell on his/her knees. The care plan update of 9/8/12, indicated the resident was continually removing the clip alarm and the family refused to try an alarmed seat belt. "There was a question of changing the chair clip alarm to a talking sensor alarm secondary to the resident continually removing the clip." There was no documentation to indicate the facility reapproached the family regarding the alarmed seatbelt and/or the talking sensor alarm. The care plan did not indicate if the talking sensor alarm was implemented. The incident/accident follow-up report dated 9/8/12, indicated a rehabilitation screen would be completed and to change the clip alarm to a talking sensor alarm. According to the incident/accident report, the resident continues to attempt to go to the bathroom without assistance and shuts off the chair alarm. The rehabilitation screen dated 9/11/12, indicated the resident continues to demonstrate poor safety due to the resident's decrease in cognition and requires constant verbal cues for safety. The rehabilitation screen did not indicate if the talking sensor alarm was implemented. On 2/7/13 at 10:15 A.M., Unit Manager #3 said the talking sensor alarm was implemented after the resident's 9/8/12 fall. During 2 of 4 days of survey (2/6/13 at 10:00 A.M., 3:30 P.M., and 4:15 P.M. and 2/7/13 at 11:30 A.M.), the resident was observed seated in a wheelchair in her/his bedroom. A large bruise (approximately 2 inches by three inches) was observed on the resident's right forehead. A talking sensor alarm (which was a talking alarm and spoke to the resident when the resident got up from the wheelchair) was observed and heard from the resident's bedroom. Further record review on 2/7/13, indicated that a nursing note dated 12/25/12 at 6:00 A. M, documented that the resident was found on the bathroom floor. The resident sustained [REDACTED]. The 12/25/12 nursing note did indicate the resident's sensor alarm had sounded. The incident/accident follow-up report indicated 12/31/12, indicated a rehabilitation screen was to be completed. The rehabilitation screen dated 1/3/13, indicated the resident was at baseline level of functioning and should be assisted with all transfers. The screen also indicated the resident managed to turn off the alarm. No new interventions were implemented which addressed the resident's ability to turn off the alarm. A nursing note dated 2/3/13 at 10:50 P.M., indicated the resident was found in the bathroom. According to the nursing note, the resident was found lying on the right side with a skin tear on the right knee and right elbow and a bruise to the right forehead. The physician was notified and ordered the resident be sent to the hospital. The resident returned to the facility with a [DIAGNOSES REDACTED]. Again, the incident/accident follow-up report dated 2/3/13, indicated a rehabilitation screen would be completed. A three day bladder and bowel pattern would be reinstated, even though the resident was diagnosed with [REDACTED]. The rehabilitation screen dated 2/5/13, indicated the resident would benefit from skilled services. However, the resident refused to participate in an evaluation." Will continue to monitor." For Resident #19, four of the seven falls (9/2/12, 9/8/12, 12/25/12 and 2/3/13), involved the resident trying to use the bathroom and falling out out her/his wheelchair. The three other falls (7/18/12, 8/19/12 and 8/19/12), the resident fell from the wheelchair while in the bedroom. The facility failed to comprehensively reassess the resident after each of these falls in order to determine an effective intervention to prevent further fall and injury. On 2/7/13 at 10 :30 A.M., Unit Manager #3 said it was her understanding that it was the facility's policy to have a rehabilitation screen completed after each resident's fall. Unit Manager #3 also said the interventions for Resident #19 could be reassessed to determine new interventions to prevent further fall and injury. 5. For Resident #11 the facility failed to prevent the resident from falling 16 times between 8/5/12 and 2/13/13. Resident #11 was admitted to the facility in 8/2012 with [DIAGNOSES REDACTED]. Review of the initial minimum (MDS) data set [DATE], indicated that the resident transferred with extensive assistance, ambulation with limited assistance was continent of bowel and bladder and had fallen in the past. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of the fall care plan dated 8/2/12, indicated the following interventions: * Call light within resident's reach * Remind resident to use call light for assistance * Verbal cues for safety * Maintain a safe and clutter free environment * Keep room well lit at night * Keep all needed items near resident for easy accessibility * OT/PT (occupational therapy/physical therapy) consult PRN (as needed) * Provide proper footwear - remind to wear * Remind resident to use assistive devices * Discourage resident from getting-up unassisted if feeling dizzy, drowsy, not fully alert * Safety checks as needed * Respond to call light promptly * Incontinence care promptly * Transfer with 1 assist * Address toileting needs promptly Record review of the medical record indicated the following falls: Fall #1 On 8/5/12 at 2:30 A.M., the resident was found on the floor in the bathroom. The resident indicated that "I slid when I tried to go the bathroom." The intervention to prevent further accidents was to provide a rehabilitation screen and to educate the resident to call for help. Review of the 8/6/12 rehabilitation screen indicated that the resident was already being provided with skilled PT services. Fall #2 On 9/8/12 at 9:30 A.M., the resident fell while reaching to plug in his/her phone charger. The intervention to prevent further accidents indicated that the facility put Dycem on the wheelchair. Review of the rehabilitation screen indicated that the resident was currently being provided with skilled PT services with a focus on balance and safety. Fall #3 On 9/8/12 at 8:00 P.M., the resident was walking with a walker when his/her legs slid out from under him/her. The intervention to prevent further accidents was to provide a rehabilitation screen and to educate the resident to call for help. Both of these interventions had been included in the plan of care on 8/5/12. The plan of care was not changed. Fall #4 On 9/11/12 at 6:30 P.M., the resident was trying to get out of bed to his/her wheelchair. The resident sat on the floor when he/she was unsuccessful in getting into the chair. The intervention to prevent further accidents was to provide a rehabilitati