Every finding on record at Kimball Farms Nursing Care Center

Based on records reviewed and interviews for one of three sampled Residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) documentation related to meal intake was incomplete.Findings include:Review of the Facility's Policy titled, Clinical Documentation, dated as last revised 12/29/25, indicated:-This facility meets Department of Public Health requirements for weekly summary of resident condition by ensuring documentation of medication and treatment administration every shift, interdisciplinary progress notes as needed, skin evaluations weekly, and Functional Performance point of care documentation every shift. -Nursing Assistant Documentation should be completed at Point of Care using the Electronic Health Record. Resident #1 was admitted to the Facility in May 2025, diagnoses included Dementia and Generalized Anxiety Disorder. Review of Resident #1's Meal Intake by Day report (CNA Documentation that indicates the amount of food and fluids a resident consumes daily) indicated for the following meals, the intake amount was left blank. July 2025Breakfast: 2 out of 31 opportunities left blankLunch: 7 out of 31 opportunities left blankAugust 2025Breakfast: 4 out of 31 opportunities left blankLunch: 7 out of 31 opportunities left blankDinner: 1 out of 31 opportunities left blankSeptember 2025Breakfast: 6 out of 30 opportunities left blankLunch: 10 out of 30 opportunities left blankOctober 2025Breakfast: 7 out of 23 opportunities left blankLunch: 12 out of 23 opportunities left blankDinner: 1 out of 23 opportunities left blank.During an interview on 01/13/26 at 4:45 P.M., the Director of Nursing (DON) reviewed Resident #1's CNA Documentation, and she said anywhere there are blank spaces, the CNA should have entered the appropriate amount of food and fluids consumed, especially given the fact that he/she had experienced significant weight loss. The DON said if there are any blank spaces, that meant the CNA did not complete their documentation, as required.

Based on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for six Residents (#43, #25, #5, #8, #3, and #40) out of a total sample of 17 residents, and on two units (Windemere and [NAME]) out of a total of three units. Specifically, the facility failed to ensure that:1) for Resident's #43, #25, #5, #8 and #3, who resided on the Windemere unit, the facility staff used the correct Personal Protective Equipment (PPE: items such as gowns, masks, eye protection or gloves that are used to prevent the spread of infection) for residents who were on Contact/Droplet Isolation for COVID-19 infection placing other residents and staff at risk of cross contamination and infection. 2) for Resident #40, who resided on the Sedgewick Unit, the facility staff followed Enhanced Barrier Precautions (EBP: the use of PPE for residents who are at higher risk of contracting an infection) during high contact care for a Resident with an indwelling urinary catheter device placing him/her at risk for the spread of infection. Findings include: Review of the facility policy COVID-19 Prevention and Outbreak Management, revised 9/17/25, indicated the following: -It is the practice of this facility to follow the guidance of government resources including Centers for Disease Control and Prevention (CDC), Centers for Medicaid and Medicare Services (CMS), Massachusetts Department of Public Health (DPH), and American Health Care Association (AHCA). -Positive COVID-19 Screening: >Immediately place the resident on Isolation/special Droplet precautions. Review of the CDC's Infection Control Guidance: SARS-CoV-2 [COVID-19 infection] dated 6/24/24 indicated the following: -This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. -Personal Protective Equipment >HCP [health care providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 should adhere to Standard Precautions [a set of precautions such as washing hands before and after contact with a patient and use of gloves when coming in contact with bodily fluids is likely to prevent the spread of infection] and use a NIOSH [National Institute for Occupational Safety and Health] Approved particulate respirator with N95 or higher [a type of mask that filters out small infectious particles carried in the air], gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the Isolation Droplet/Contact Precautions signs in use in the facility indicated the following: -In addition to standard precautions staff and providers must use: >Gown >N95 Respirator >Eye protection >Gloves 1a. On 12/3/25 at 8:36 A.M., the surveyor observed Unit Manager (UM) #2 delivering a breakfast tray to Resident #43. The surveyor observed the following: -an Isolation Droplet/Contact Precautions sign was observed on the outside of the doorway of Resident #43's room. -UM #2 was observed to enter the Resident's room with a surgical mask already in place, without donning (putting on) a gown, gloves, eye protection or changing her surgical mask to a N95 Respirator mask and deliver the breakfast tray to the Resident. -UM #2 was observed to exit the room, observe the signage outside of the Resident's doorway and then perform hand hygiene. -a PPE cart was observed nearby in the hallway with an ample supply of gowns, gloves, face shields and N95 Respirators. During an interview on 12/3/25 at 9:33 A.M., UM #2 said that she initially thought the sign outside of the Resident's room was for EBP as she was not aware the Resident had COVID-19. UM #2 further said she should have worn the required PPE when delivering the Resident's meal tray but did not. 1b. On 12/3/25 at 8:41 A.M., the surveyor observed the following while Certified Nurse's Aide (CNA) #5 was delivering breakfast trays: -CNA #5 donned the appropriate PPE and served a tray to Resident #25 where an Isolation Droplet/Contact Precautions sign was posted outside the Resident's door. -CNA #5 exited Resident #25's room and doffed (removed) the face shield, gown and gloves and performed hand hygiene. -CNA #5 donned a new gown, gloves and face shield and entered Resident #5's room where an Isolation Droplet/Contact Precautions sign was posted outside the door and delivered a tray to Resident #5 without doffing the N95 Respirator worn in Resident #25's room and donning a new N95 Respirator. During an interview on 12/3/25 at 9:24 A.M., CNA #5 said that she was supposed to change her N95 Respirator after exiting a room where a Resident is COVID-19 positive, but she had not. 1c. On 12/3/25 at 9:23 A.M., the surveyor observed Nurse #3 getting ready to enter Resident #8's room where an Isolation Droplet/Contact Precautions sign was posted outside the door. Nurse #3 was observed to drop the PPE gown she was donning on the floor, pick up the gown from the floor and donned the same gown before entering the Resident's room. During an interview on 12/3/25 at 9:40 A.M., Nurse #3 said that she should not have donned the gown that fell on the floor because the floor is dirty. 1d. On 12/3/25 at 9:40 A.M., the surveyor observed the following relative to CNA #4: -CNA #4 entered Resident #8's room, where an Isolation Droplet/Contact Precautions sign was posted outside the door, without donning eye protection. -CNA #4 exited Resident #8's room after doffing his gown and gloves. -CNA #4 performed hand hygiene and donned a new gown and gloves. -CNA #4 then entered Resident #3's room, where an Isolation Droplet/Contact Precautions sign was posted outside the door, without donning eye protection. During an interview on 12/3/25 at 9:47 A.M., CNA #4 said he was unsure if he should have worn eye protection in Resident #8's and Resident #3's rooms. The surveyor and CNA #4 reviewed the Isolation Droplet/Contact Precautions sign posted outside of Resident #3's room and CNA #4 said he should have worn eye protection but was unsure why this was important. During an interview on 12/3/25 at 10:03 A.M., the surveyor reviewed the (UM #2, CNA #5, Nurse #3 and CNA #4) observations with the Infection Control Preventionist (ICP). The ICP said that UM #2 should have worn PPE when entering a room with an Isolation Droplet/Contact Precautions sign posted outside the door, CNA #5 should have changed her N95 Respirator after exiting a room with an Isolation Droplet/Contact Precautions sign posted outside the door, CNA #4 should have worn eye protection in a room with an Isolation Droplet/Contact Precautions sign posted outside the door, and did not comment on Nurse #3. The ICP further said that not wearing or changing PPE as indicated was a concern due to the risk of transmission of infection. 2. Resident #40 was admitted to the facility in January 2024 with multiple diagnoses including obstructive and reflux uropathy and resided on the Sedgewick Unit. Review of the facility policy titled Infection Prevention and Control Manual, dated 1/10/23 indicated the following in part: -Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDRO's) to staff hands and clothing. MDRO's may be indirectly transferred from resident to staff during these high contact activities. -EBP will be used in these conditions: All residents on the unit with indwelling medical devices e.g., .urinary catheter. -EBP require gowns and gloves for all high contact care. Examples: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care . urinary catheter. Review of Resident #40's December 2025 Physician orders indicated an order dated 8/11/25, to maintain the Foley Catheter (an indwelling urinary catheter used to drain urine from the bladder) every shift. On 12/3/25 at 8:31 A.M., the surveyor observed the following outside Resident #40's bedroom: -EBP signage was posted outside of the Resident's bedroom. -A PPE bin was located outside of the Resident's room and was stocked with gowns and gloves. -Resident #40's bedroom door was closed. -CNA #2 said that CNA #1 was in Resident #40's room providing care for the Resident. -CNA #1 exited Resident #40's room while removing her gloves. CNA #1 was not wearing a PPE gown at this time. During an interview on 12/3/25 at 9:46 A.M., CNA #2 said staff are required to wear PPE when providing care for Resident #40 because the Resident had a urinary catheter. During an interview on 12/3/25 at 9:48 A.M., CNA #1 said she was not aware Resident #40 had an EBP sign on his/her door and she did not wear the appropriate PPE when providing care this morning for the Resident. CNA #1 said she and another CNA provided care for Resident #40 and she could not recall if anyone in the room had on the correct PPE when providing care for the Resident but should have because Resident #40 had a catheter.

Based on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#58), of three applicable residents, out of 26 medication pass opportunities. The medication error rate was observed to be 15.38%. Specifically, for Resident #58, the facility staff administered: Potassium Citrate (essential mineral) and Metoprolol Succinate (blood pressure medication) medications that were crushed when the orders specified do not crush.A chewable Aspirin (blood thinner that prevents clots forming in the blood) instead of the ordered Enteric Coated (coating on the medication that allows the medication effect to be longer lasting) Aspirin.Polyethylene Glycol eye drops (type of lubricating eye drops) instead of the ordered Dextran 70/Hypromellose 0.1% - 0.3% eye drops (another type of lubricating eye drops). Findings include: Review of the Lippincott Nursing Procedures Ninth Edition (2023) manual indicated the following: -Verify the order on the patient's medication record by checking it against the practitioner's order. -Compare the medication label against the order in the patient's medical record. -If the patient can't swallow a whole tablet or capsule, ask the pharmacist whether the drug is available in liquid form or can be administered by another route. If not, request a crushed tablet (if appropriate) or discuss whether you can crush the tablet yourself or open the capsule and mix it with food. Keep in mind that many enteric-coated timed-released medications and gelatin capsules shouldn't be crushed to prevent possible adverse effects. Contact the practitioner for an order to change the route of administration when necessary. -To help prevent polypharmacy (taking many medications which places a person at greater risk of side effects and drug interactions), you can help older adult patients manage and adhere to their medication regimens by instructing them to take the following actions: >Take medications exactly as directed. Review of the facility policy titled Administration Procedure for all Medications, dated 9/20/23, indicated the following: -Purpose: to administer medications in a safe and effective manner. -Procedure: >Check MAR [Medication Administration Record] for order >Read medication label three times: 1) prior to removing medication package/container from the cart/drawer; 2) prior to removing medication from the package/container; 3) as the package/container is returned to the cart/drawer. Compare label to MAR. Due to the complexity and length/ amount of instructions, some medications may be labeled as use as directed. Refer to MAR for instruction details. Resident #58 was admitted to the facility in July 2024 with the diagnoses including Dementia and Heart Failure. Review of Resident #58's December 2025 MAR indicated: -an active order for Aspirin 81 milligrams (mg) tablet, enteric coated. Give one tab orally at 9:00 A.M., initiated 7/15/24. -an active order for Metoprolol Succinate 50 mg tablet, extended release. Give one tab orally at 9:00 A.M.swallow whole, do not crush or chew. initiated 7/15/24 -Potassium Citrate 10 milliequivalents (mEq) tablet, extended release. Give Two tabs orally twice a day.swallow whole, do not crush or chew.initiated 7/15/24. -Natural Tears (Dextran 70/Hypromellose 0.1% - 0.3% solution). Give two drops to bilateral eyes, initiated 7/22/25 On 12/5/25 at 7:53 A.M., the surveyor observed the following while Nurse #2 prepared and administered medications for Resident #58: -Nurse #2 poured two Potassium Citrate 10 mEq Extended-Release tablets into the medication cup -Nurse #2 poured one Metoprolol Succinate 50 mg Extended-Release tablets into the medication cup -Nurse #2 poured one chewable Aspirin 81 mg tablet into the medication cup -after pouring all other ordered medications into the cup, Nurse #2 crushed all tablets together and mixed them with pudding -After Nurse #2 prepared the medications, she administered the medication and pudding mixture to Resident #58. -Nurse #2 then administered two drops of Polyethylene Glycol eye drops in each of Resident #58's eyes. During an interview on 12/5/25 at 8:13 A.M., the surveyor and Nurse #2 reviewed Resident #58's MAR and Nurse #2 said the orders on the MAR for Potassium Citrate and Metoprolol Succinate indicated that these medications should be taken whole, do not crush and that she had crushed them when she administered the medications but should not have. Nurse #2 said the order for the eye drops specified Natural Tears (Dextran 70/Hypromellose 0.1%-0.3%) and that she had administered Polyethylene Glycol but should not have. Nurse #2 further said the order for Aspirin indicated to give the enteric coated form, but she had given the chewable form and should not have. Nurse #2 said she should have contacted the Provider to obtain orders for different forms of the medications instead of administering medications that did not follow the Physician orders. During an interview on 12/5/25 at 10:01 A.M., the Director of Nursing (DON) said the concern with Nurse #2 not following the Physician orders was that there could be an adverse reaction to the medication administration to Resident #58.

Based on interview, record and record review, the facility failed to coordinate assessments with the Preadmission and Resident Review (PASRR) Unit (state office that identifies evidence of serious mental illness [SMI] and/or intellectual or developmental disabilities [ID/DD] in all individuals seeking admission to a nursing facility that is Medicaid or Medicare certified) for one Resident (#55) out of a total sample of 18 residents. Specifically, for Resident #55, the facility failed to ensure a Level II Resident Review (Level II Evaluation - a comprehensive independent evaluation conducted by the appropriate state designated authority that determines whether an individual has a mental disorder [MD], ID or a related condition, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs. The Level II PASRR cannot be conducted by the nursing facility) was completed when it was identified Resident #55 would exceed their PASRR Level II Provisional Emergency Determination (Provisional Emergency - A Categorical Determination (CD) that applies when an individual seeking admission to a nursing facility requires protective services or seeks admission during an emergency situation on a night, weekend, or holiday. The provisional emergency CD is time-limited, and individuals admitted to a nursing facility under this CD may remain for a maximum of seven calendar days before the individual must receive a post-admission screening). Findings include: Review of the facility policy titled Preadmission Screening and Resident Review (PASRR), revised 9/22/23, indicated the following: -Post Admission Responsibilities -Expiration of Exempted Hospital Discharge (EHD) or Categorical Determination (CD) (SMI Only) -Facility must notify when resident will not be discharged before expiration of EHD stay and needs to request a Level II PASRR from the Department of Mental Health (DMH) or their Designee. -Facility determines the resident will not be discharged before expiration of the CD selected below and is requesting a Level II PASRR from the Department of Mental Health (DMH) or Designee. -Convalescent Care -Provisional Emergency -Respite Resident #55 was admitted to the facility February 2024 with diagnoses of Unspecified Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances) and Major Depressive Disorder. Review of the PASRR Abbreviated Level II Evaluation Determination Summary, dated 2/17/24, indicated the following: -Your PASRR Level II evaluation has been completed. It has been determined that you are appropriate for a Provision Emergency admission to a Nursing Facility that cannot exceed-7-calendar days. Should the length of your stay in the nursing facility need to exceed the 7-calendar day approval of the Provisional Emergency, the nursing facility must submit request on your behalf for an additional Level II Resident Review by the 2nd calendar day after your admission. Further review of the Resident's medical record indicated no documentation the PASRR Unit received an updated PASRR Level I Screening-Expiration of EHD/CD when Resident #55 exceeded his/her 7-calendar day approval to evaluate the need for an additional PASRR Level II Evaluation. During an interview on 8/14/24 at 2:09 P.M., the Social Worker said she was unable to provide the original PASRR Level I Preadmission Assessment. The SW said she only had a PASRR Level II Evaluation for Provisional Emergency CD and it indicated a PASRR Level I Screening-Expiration of EHD/CD should have been submitted when it was determined the Resident would exceed his/her Provisional Emergency 7-calendar day approval and she was unable to provide any documentation to show the PASRR Unit had received and reviewed an updated PASRR Level I Screening once the Resident exceeded the 7-calendar day approval.

Based on interview, record and policy review, the facility failed to notify the State Mental Health Authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#120) out of a total sample of 18 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness[SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #120 received emergency mental health interventions and experienced limitations in major life activities due to mental illness. Findings include: Review of the facility policy titled Preadmission Screening and Resident Review (PASRR), revised on 9/22/23 indicated the following in part: -Resident-Significant Change --Referral to DDS (Department of Developmental Services)/DMH (Department of Mental Health) by Affiliate is necessary when resident has experienced a significant change in condition (mental illness or health status) that may impact the residents PASRR disability status, the appropriateness of SNF (Skilled Nursing Facility) placement and/or specialized services. --Requires interdisciplinary review or revision of the care plan; and may result in a positive Level I Screen for SMI (Serious Mental Illness) .or may result in a change in previous PASRR determinations. Resident #120 was admitted to the facility in June 2023, with the following diagnoses: Major Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review of the PASRR Level I Screen (initial pre-screening completed prior to admission to a Nursing Facility) dated 6/28/23, indicated the following: -Resident #120 had a documented mood disorder (Bipolar Disorder/Major Depression). -In the past two years the Resident did not have any treatments due to SMI. -In the past six months or currently, the Resident did not have limitations in major life activities due to SMI. -Negative Level I Screen result, indicating a Level II PASRR evaluation was not needed. Review of the Social Service progress note dated 7/29/24, indicated the following: -Social Worker (SW) made aware that the Resident had an incident which appeared to be a suicide attempt. -He/she was immediately sent to the ER while the covering SW worked on a psych hospital referral as it was clear he/she needed an inpatient stay. Further review of the medical record indicated no documented evidence that a PASRR resident review had been conducted after a significant change in mental condition occurred, that may have resulted in a positive Level I Screen for SMI or a change in the previous PASRR determination. During an interview on 8/14/24 at 3:45 P.M., the SW said that Resident #120 was sent out on 7/24/24 due to a change in his/her mental health and suicide attempt. The SW said that the Resident was sent to the hospital for safety, followed by a transfer to an in-patient psychiatric program. The SW said that she was unable to locate any additional PASRR Screens in the medical record, only the Level I screen dated 6/28/23. The surveyor and SW reviewed the Level I PASRR dated 6/28/23 and noted it to indicate the following at the top of the form: -Resident review (Level I Screening Form required if Significant Change in Condition: newly indicated Serious Mental Illness (SMI), exacerbation of SMI, or improvement/decline in condition). The SW said that a Resident Review should have been completed and then submitted to the PASRR office as the Resident had a significant change in his/her SMI indicating that a Level II PASRR should have been requested.

Based on interview, record and policy review, the facility failed to offer the Pneumococcal (infections caused by bacteria called Streptococcus Pneumoniae, or Pneumococcus that can cause Pneumonia and blood stream infections) Vaccination as recommended to one Resident (#57), out of five applicable residents, out of a total sample of 18 residents. Specifically, the facility failed to ensure that Pneumococcal Vaccinations were offered to, received by, or declined by Resident/Resident Representative #57 at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility policy titled Resident Pneumococcal Immunization, effective 9/2011, and revised 9/1/23, indicated: -Residents .will be offered immunization to protect them from Pneumococcal disease unless the vaccine is medically contraindicated, or the resident has already been immunized. -Pneumococcal Immunizations will be provided as recommended by the Center for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP) recommendations. -Immunization status will be reviewed to determine eligibility for immunization. -CDC link Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov) included other adults and indicated that adults age 19-64 with certain underlying medical conditions or other risk factors who have not previously received a Pneumococcal Conjugate Vaccine (PCV - a vaccine that helps protect against diseases caused by pneumococcal bacteria) or whose previous vaccination status is unknown should receive one dose of PCV (either PCV-20 [protects against 20 types of pneumococcal bacteria] or PCV-15 [protection for 15 types of pneumococcal vaccines]), adults who have received PPSV-23 (Pneumococcal Polysaccharide Vaccine 23 [protect against serious infections caused by 23 types of pneumococcal bacteria]) only may receive a Pneumococcal Conjugate Vaccine (either PCV-20 or PCV-15) equal to or greater than one year after their last PPSV-23 dose. -Residents with unknown or uncertain immunization status may be immunized, as the benefit of immunization outweighs any risk related to re-immunization. -If there is no prior evidence of vaccination, vaccine status is unknown or uncertain, the vaccine will be offered in accordance with CDC ACIP recommendations. Resident #57 was admitted to the facility in June 2023, with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), and Parkinson's Disease (a chronic degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) and age was greater than 65 at the time of admission. Review of the Resident's Consent for Influenza and/or Pneumococcal and/or COVID Vaccine Form, dated 10/18/23, indicated no documented evidence that the Pneumococcal Vaccine information had been provided or that the Resident/Resident Representative had given consent or declined the PCV-20 or the PPSV-23 vaccine (the sections were blank). Review of the facility's Immunization Record for Resident #57 indicated the PCV-20 immunization was offered and declined on 7/30/24. During an interview on 8/14/24 at 9:17 A.M., the surveyor and the Infection Preventionist (IP) reviewed the Consent for Vaccine completed on 10/18/23. The IP said the Vaccine Consent form did not indicate that the Pneumococcal Vaccine information had been provided or that the vaccine had been consented to or declined. The surveyor and the IP reviewed the Immunization Record documentation entry dated 7/30/24, that indicated the PCV-20 Vaccine had been offered and declined. The IP said that she had documented that the PVC-20 was offered and declined because the consent had not been obtained. The IP further said that she should have called the Resident Representative and offered the vaccine prior to documenting that the vaccine had been offered and declined. The IP said the Resident/Resident Representative should have been provided with vaccine information and offered the vaccine if it was consented to, but that she had not done this. During an interview on 8/14/24 at 9:43 A.M., the IP said that she had provided vaccine information to Resident #57's Resident Representative and he/she consented for the Resident to receive the PCV-20 and PPSV-23 vaccinations. The IP said the Resident should have received the PCV-20 vaccine.

Based on record review and interview, the facility failed to ensure its staff completed Quarterly Minimum Data Set (MDS) Assessments within the required timeframe for 12 Residents (#10, #17, #23, #26, #29, #41, #43, #50, #53, #61, #66 and #73 out of 14 sampled residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual, dated October 2019, indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD- refers to the last day of the observation period that the assessment covers for the resident). 1. Resident #10 was admitted to the facility in January 2021. Review of the medical record indicated the 4/14/23 Quarterly MDS Assessment was not completed. 2. Resident #17 was admitted to the facility in January 2023. Review of the medical record indicated the 4/13/23 Quarterly MDS Assessment was not completed. 3. Resident #23 was admitted to the facility in September 2021. Review of the medical record indicated the 4/21/23 Quarterly MDS Assessment was completed 5/17/23. 4. Resident #26 was admitted to the facility in December 2022. Review of the medical record indicated the 4/21/23 Quarterly MDS Assessment was not completed. 5. Resident #29 was admitted to the facility in September 2016. Review of the medical record indicated the 4/14/23 Quarterly MDS Assessment was not completed. 6. Resident #41 was admitted to the facility in May 2018. Review of the medical record indicated the 4/7/23 Quarterly MDS Assessment was completed 5/17/23. 7. Resident #43 was admitted to the facility in July 2020. Review of the medical record indicated the 4/7/23 Quarterly MDS Assessment was completed 5/17/23. 8. Resident #50 was admitted to the facility in January 2022. Review of the medical record indicated the 4/21/23 Quarterly MDS Assessment was not completed. 9. Resident #53 was admitted to the facility in January 2020. Review of the medical record indicated the 4/14/23 Quarterly MDS Assessment was not completed. 10. Resident #61 was admitted to the facility in December 2021. Review of the medical record indicated the 4/7/23 Quarterly MDS Assessment was completed 5/17/23. 11. Resident #66 was admitted to the facility in January 2022. Review of the medical record indicated the 4/14/23 Quarterly MDS Assessment was not completed. 12. Resident #73 was admitted to the facility in January 2023. Review of the medical record indicated the 4/14/23 Quarterly MDS Assessment was not completed. On 5/18/23 at 12:45 P.M., the MDS nurse said the Quarterly MDS Assessments for Residents #10, #17, #23, #26, #29, #41, #43, #50, #53, #61, #66, and #73 were not completed within the required timeframe.

Based on record review and interview, the facility failed to ensure its staff completed Discharge Minimum Data Set (MDS) Assessments for three Residents (#19, #70 and #73) out of 14 sampled Residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual, dated October 2019, indicated the Discharge MDS Assessment must be completed no later than 14 calendar days after the date of discharge from the facility. 1. Resident #19 was admitted to the facility in December 2022. Review of the medical record indicated the Resident was discharged from the facility on 4/19/23. Further review of the medical record indicated no Discharge MDS Assessment was completed. 2. Resident #70 was admitted to the facility in April 2023. Review of the medical record indicated the Resident was discharged from the facility on 4/19/23. Further review of the medical record indicated no Discharge MDS Assessment was completed. 3. Resident #73 was admitted to the facility in January 2023. Review of the medical record indicated the Resident was discharged from the facility on 4/17/23. Further review of the medical record indicated no Discharge MDS was completed. On 5/19/23 at 11:51 A.M., the MDS Nurse said the required Discharge MDS Assessments for Residents #19, #70 and #73 were not completed, as required.

Based on record review and interview the facility failed to ensure its staff accurately completed Minimum Data Set (MDS) Assessments for three Resident's (#44, #60, and #25) out of a total of 18 residents sampled. Specifically, the facility staff failed to accurately code an MDS Assessment relative to falls for Resident #44, mood assessment for Resident #60, and use of an antidepressant for Resident #25. Findings include: 1. Resident #44 was admitted to the facility in April 2023. Review of a nurses note dated 5/3/23 indicated Resident #44 fell on this date and was subsequently transferred to the hospital to be evaluated. Review of MDS Assessment with a target date of 5/5/23 indicated that the Resident had no falls since admission/entry, re-entry, or the prior assessment. During an interview on 5/18/23 at 1:06 P.M., The MDS Nurse said that the review period for this assessment was from 4/28/23 through 5/5/23 and should have indicated that the Resident did have a fall since admission/entry, re-entry or prior to this assessment and it did not. 2. Resident #60 was admitted to the facility in February 2023. Review of the MDS assessment dated [DATE] indicated the following: Section B (Hearing, Speech, and Vision) -Resident is not in a vegetative state -Had the ability to hear adequately -Had clear speech with distinct intelligible words -Made self-understood -Had the ability to clearly comprehend others. Section D (Mood) -Mood interview should not be conducted because the Resident is rarely or never understood. During an interview on 5/18/23 at 1:06 P.M., the MDS Nurse said that interviews are to be done if the resident can answer the questions. She said that if a resident does not give an answer or the answers are so abstract that it does not make any sense, then it will be noted that they are not able to answer, and a staff interview would then be completed. She said that if the resident is capable, then the interview should be attempted. She continued to say that for this case the interview should have been conducted with Resident #60 and was not. 44129 3. Resident #25 was admitted to the facility in February 2023. Review of the MDS assessment dated [DATE] indicated the Resident received an antidepressant medication on six out of the last seven days, since admission. Review of the Resident's record indicated no physician's orders for an antidepressant medication. On 5/13/23 at 3:08 P.M., the Director of Nursing (DON) said the Resident was never prescribed an antidepressant medication and the the MDS Assessment should be modified to reflect this.

Based on observations and interviews, the facility failed to A.) ensure a medication cart was clean and sanitary, on one of three units, and B.) failed to ensure stored narcotics were properly labeled, on two of three units. Findings include: A.) During an observation on [DATE] at 7:46 A.M. of the [NAME] Unit Medication Cart #3 with Nurse #3, the third medication drawer was found to be very sticky with a brown substance spilled onto the floor of the drawer. There were other bottles in the same drawer that were sticking to the floor of the drawer and they could not be easily removed from the drawer for usage. During an interview, on [DATE] at 7:50 A.M., Nurse #3 said the third drawer of the medication cart had a brown, sticky substance on the floor of the drawer and had not been cleaned, as required. B.) The facility failed to ensure narcotics were properly labeled when stored on two of three units. - During the observation on [DATE] at 7:57 A.M. of the Sedgewick Unit Medication Cart #4 with Nurse #4, one random opened bottle of [MEDICATION(S)] (MS04-a narcotic) Liquid 15 milliliter (ml) with a syringe was found in a clear plastic cup. The MS04 bottle was not labeled with a resident name nor a prescribed dose. During an interview, on [DATE] at 9:13 A.M., Nurse #4 said the MS04 bottle belonged to a specific resident that had expired a week ago. She further said the MS04 was not labeled with a resident name nor a prescribed dose, as required. - During an observation on [DATE] on 9:10 A.M. of the Windemere Unit Medication Cart #2 with Nurse #5, three bottles of opened MS04 15 ml were found in the narcotic drawer. Each bottle was stored in a clear, plastic drinking cup. Each cup had a specific resident name written on it, however the MS04 bottles did not have a label indicating a specific resident or a prescribed dose. During an interview, on [DATE] at 9:15 A.M., Nurse #2 said none of the three MS04 bottles that were stored in the plastic cups had a label with a resident's name and a prescribed dose, as required. During an interview, on [DATE] at 1:14 P.M., the Director of Nurses (DON) said the MS04 bottles are obtained from the Pyxis (an automated medication dispensing system) when needed. She said the MS04 bottles are only labeled with the medication name and strength. She further said by storing the bottles in a plastic cup and hand labeling the cups with a resident name, there is room for error and that the bottles were not labeled with a specific resident name and dosage ordered, as required.

Based on observations, interviews and record reviews, the facility failed to follow infection control guidelines relative to A.) conducting hand hygiene to prevent the potential spread of infection, and B.) administering a Covid-19 test for one sampled Resident (#22), out of a total of 18 residents. Findings include: 1. The facility failed to ensure staff conducted hand hygiene before donning and after doffing gloves during a dressing change procedure. Review of the facility's policy titled, Aseptic Dressing Change and Wound Measurement, dated 10/1/10, indicated, but is not limited to: - Remove and discard disposable gloves in a plastic bag at bedside. - Perform hand hygiene. During an observation, on 8/18/21 at 11:00 A.M., Nurse #5 donned and doffed gloves numerous times during a dressing change procedure. Nurse #5 did not sanitize her hands after doffing soiled gloves and before donning new gloves two times during the procedure. During an interview, on 8/18/21 at 12:26 P.M., Nurse #5 said she did not realize she did not sanitize her hands, as required. 2. During the dressing change procedure, Certified Nurse Aide (CNA) #1 was observed standing on the side of the bed, rubbing the back of the Resident with her ungloved hands. Once the procedure was complete, CNA #1 applied gloves to provide personal care to the Resident. She did not sanitize her hands prior to donning gloves. Review of the facility policy's policy titled, Donning and Doffing PPE-COVID Pandemic, revised 1/18/21, indicated, but is not limited to: -Proper sequence for donning PPE, perform hand hygiene by using : a. alcohol-based hand rub b. soap and water for 20 seconds -Proper sequence for doffing PPE, perform hand hygiene when exiting the room: a. alcohol-based hand rub During an interview, on 8/18/21 at 2:08 P.M., CNA #1 said she did not sanitize her hands prior to donning gloves, as required. 3. On 8/18/21 at 8:50 A.M., the surveyor observed CNA #3 exit a Residents' room, doff (take off) and dispose of her gloves. She then opened the clean PPE container, located in the hallway, removed and donned a new face shield. CNA #3 proceeded to the clean linen cart and removed towels before entering a Residents room. When she was asked how often hand hygiene should be done, CNA #3 said she was supposed to wash her hands after taking off her gloves and did not, as required. During an interview, on 8/19/21 at 1:16 P.M., the Infection Control Nurse said that it is an expectation that when staff remove their gloves, they should immediately perform hand hygiene. 4. For Resident #22, the facility failed to follow their policy relative to conducting a Covid-19 test when signs/symptoms of infection were present. Review of the facility policy entitled Covid-19 Prevention and Outbreak Management, revised 8/4/21, indicated the following: -A positive Covid -19 screening include: temperature equal to or greater then 100 degrees Fahrenheit, chills, new or worsening cough, shortness of breath, muscle aches, new onset loss of taster or smell, fatigue, headache, sore throat, running nose, gastrointestinal symptoms such as nausea, vomiting, diarrhea . -if worsening OR new onset of Covid symptoms OR if temperature is 100 degrees Fahrenheit or greater, call the physician, -test the resident per testing policy using BinaxNOW and PCR (polymerase chain reaction) test. -immediately place the resident on isolation/special droplet precautions -increase the frequency of Covid-19 screening to every four hours . Resident #22 was admitted to the facility in June 2021. Review of a nurse's note, dated 6/26/21, indicated Resident #22 was having difficulty breathing and wheezing during the shift. The physician was updated and new orders were obtained. Review of the nurses' notes, dated 6/27/21, indicated the Resident had a change in condition and the physician was updated. The Resident was placed on oxygen therapy at 1.5 liters per minute (LPM) and continued with intermittent wheezing. Review of the nurses' notes, dated 6/28/21, indicated the Resident was not him/herself, had chest congestion and was receiving oxygen therapy at 2 LPM (up from 1.5 previously administered). The nurse indicated the Resident was weak, required more assistance and had a low oxygen saturation level. The Resident had increased lethargy and refused dinner. Review of a nurse's note, dated 6/29/21, indicated Resident #22 continued to be lethargic and show signs of shortness of breath and wheezing. The physician was notified and new orders were given. Review of the clinical record did not indicate that Covid-19 testing was conducted during 6/26/21 through 6/29/21 time period. During an interview, on 8/18/21 at 1:35 P.M., Unit Manager (UM) #1 said Resident #22 was Covid naive (has not had Covid-19), and she was not sure why the facility did not conduct a Covid test when he/she was symptomatic from 6/26/21 through 6/29/21. The UM further said that when a resident presents with signs/symptoms consistent with Covid-19 infection, a test is conducted as part of the facility process. During an interview, on 8/19/21 at 1:27 P.M., the Infection Preventionist (IP) said that when a resident presented with Covid-19 signs/symptoms as per the screening process, the physician would be notified and the resident should be checked for Covid-19 with BinaxNOW (rapid Covid-19 test) or PCR test (polymerase chain reaction test- a molecular test that detects the virus). She said that the facility had a standing order from the Medical Director to test any residents relative to Covid-19, and that if a resident is symptomatic, the facility would test the resident, put him/her on precautions, consult with the physician and await further instructions.

Based on observations and interviews, the facility failed to ensure each resident was treated with respect and dignity relative to dining on one out of three units. Findings include: On 8/17/21 at 8:39 A.M., the surveyor observed a Resident seated in a chair in the hallway, with his/her breakfast placed on a tray table in front of him/her on the Dementia Special Care Unit (DSCU). A staff member was observed standing to the left of the Resident, and was bent over while assisting him/her with their breakfast. During the observation, the staff member remained standing over the resident while assisting him/her with the meal. On 8/18/21 at 8:24 A.M., the surveyor observed an employee seated in the dining area on the DSCU, helping a Resident with his/her meal. The employee turned and loudly said to another employee who was in the hallway, not in the same room, is she a feeder now? During an interview, on 8/19/21 at 2:53 P.M., the Director of Nurses (DON) said that the expectation is for staff to be seated next to a resident or at eye level while assisting them with meals. The DON also said, that calling a resident a feeder when they require assistance during meals is not okay. During an interview, on 8/19/21 at 3:26 P.M., the Staff Development Coordinator (SDC) said that staff should be seated while assisting residents with meals. The SDC also said that using words like feeder is a label and should not be done; other language should have been used.

Based on observations, interviews and record reviews, the facility failed to ensure the plan of care for one sampled Residents (#22) was implemented, out of a total sample of 18 residents. Findings include: For Resident #22, the facility failed to A.) provide the required assistance with meals, and B) obtain weights as ordered by the Physician. Resident #22 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A.) On 8/17/21 at 9:45 A.M. during the initial pool process, the surveyor observed Resident #22 seated in a wheelchair in the unit dining area during breakfast. No staff were present in the dining area. A set up breakfast meal was positioned on the table in front of him/her, and was untouched. The Resident's head was down, his/her eyes were closed, and he/she was holding an empty cup on his/her lap. Review of the Minimum Data Set (MDS) Assessment, dated 6/9/21, indicated Resident #22 exhibited severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15, and required extensive assistance of staff with eating. Review of the Activities of Daily Living (ADL) Care Plan, initiated on 6/2/21, indicated the Resident required physical assistance from staff with eating due to cognitive deficits, decreased endurance and generalized weakness. Review of the 8/2021 Certified Nurse Aide (CNA) care card, dated 7/1/21, indicated Resident #22 required physical assistance from staff with meals. Review of the Speech Therapy Discharge Summary, dated 7/22/21, indicated the Resident was to remain on a modified texture diet and was to have supervision during meals. Review of the survey information, provided by the facility on 8/17/21, indicated Resident #22 was listed as a resident who could be assisted by the facility's trained paid feeding assistants. On 8/18/21 at 9:05 A.M. through 10:02 A.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room during breakfast. An over bed table was positioned in front of him/her and there was no staff present in the room during the meal. On several occasions, the Resident was heard to call out somebody help me and help, I need help. The surveyor entered the Resident's room at this time, and observed the resident with a fork in his/her hand, but did not have food on the fork. On 8/18/21 at 1:41 P.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room eating lunch. There was no staff present in the room. On 8/19/21 at 8:27 A.M. through 8:38 A.M., Resident #22 was seated in the unit dayroom. He/She had a beverage and a plate containing cookies and crackers. The Resident was observed to occasionally cough while eating and was stating will somebody help me. There was no staff present during the observation. During an interview, on 8/19/21 at 8:44 A.M., Nurse #6 said Resident #22 needed to have a staff person sit with him/her during meals because he/she required assistance and supervision. During an interview, on 8/19/21 at 9:26 A.M., Nurse #1 said that the unit did not utilize the paid feeding assistants on a regular basis. She said that they were not available during breakfast on this unit and on occasion may come to the unit to ask if feeding assistance is needed, but said that this didn't happen very often. During an interview, on 8/19/21 at 9:21 A.M., Unit Manager (UM) #1 said that Resident #22's plan of care indicated that he/she required assistance with meals. She further said that the Resident's ability had improved, but thought that supervision should be provided during meals. UM #1 said that supervision means that a staff person would sit with him/her and have eyes on the Resident. UM #1 said the Resident should be eating meals in the unit dayroom, and should not be eating in his/her room. She further said that she was not aware of the Speech Therapist recommendations from 7/22/21 indicating that the Resident required supervision due to swallowing difficulties. B.) Review of the 8/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated that the Resident refused on two of those occasions and that the nurse indicated the weight was not obtained due to the Resident sleeping on three occasions. On three occasions, there was no indication why the Resident's weight was not obtained as ordered by the physician. Review of the MAR, dated July 2021, indicated that no weights were obtained for Resident #22 on ten of the 31 days. Review of the MAR, dated August 2021, indicated that no weights were obtained for Resident #22 on ten of the 18 days reviewed. Further review indicated that the Resident refused on three occasions, but no explanation was provided for the seven days that the Resident's daily weight was not obtained. During an interview, on 8/19/21 at 8:29 A.M., UM #1 said there could be numerous reasons why the Resident's weight was not obtained. She said that if the weight was not obtained, as ordered by the Physician, then a notation should be documented as to why it was not measured.

Based on interviews and record reviews, the facility failed to maintain complete and accurate medical records for two sampled Residents (#22 and #29), out of a total sample of 18 residents. Findings include: 1. For Resident #22, the facility failed to ensure his/her medical record was accurate relative to documenting Covid-19 signs and symptoms. Review of the facility policy entitled Covid-19 Prevention and Outbreak Management, revised 8/4/21, indicated the following: -residents are monitored for Covid-19 symptoms and must have their temperatures checked a minimum of one time per day -if a resident is symptomatic for Covid or positive for Covid or exposed to Covid-19, symptom monitoring is enhanced to every four hours on day and evening shift. -symptoms listed include: temperature equal to or greater then 100 degrees Fahrenheit, chills, new or worsening cough, shortness of breath, muscle aches, new onset loss of taster or smell, fatigue, headache, sore throat, running nose, gastrointestinal symptoms such as nausea, vomiting, diarrhea . Resident #22 was admitted to the facility in June 2021. Review of a nurse's note, dated 6/26/21, indicated Resident #22 was having difficulty breathing and wheezing during the shift. The physician was updated and new orders were obtained. Review of the nurses' notes, dated 6/27/21, indicated the Resident had a change in condition and the physician was updated. The Resident was placed on oxygen therapy at 1.5 liters per minute (LPM) and continued to have intermittent wheezing. Review of the nurses' notes, dated 6/28/21, indicated the Resident was not him/herself, had chest congestion and was receiving oxygen therapy at 2 LPM (up from 1.5 previously administered). The notes indicated the Resident was weak, required more assistance and had a low oxygen saturation level. The notes also indicated the Resident had increased lethargy and had refused dinner. Review of a nurse's note, dated 6/29/21, indicated Resident #22 continued to be lethargic and show signs of shortness of breath and wheezing. The physician was notified and new orders were given. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to obtain the Resident's temperature, oxygen saturation and assess for worsening or new onset of Covid-19 symptoms. The symptoms listed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Covid screening from 6/26/21 through 6/29/21 did not indicate Resident #22 had shortness of breath nor malaise as indicated in the nurses' notes. During an interview, on 8/18/21 at 1:35 P.M., Unit Manager (UM) #1 said she could not explain why the MAR from 6/26/21 through 6/29/21 time period did not match what was documented in the progress notes relative to Resident #22's COVID-19 symptoms. 2. For Resident #29, the facility failed to ensure it maintained complete documentation relative to a change in his/her condition. Resident #29 was admitted to the facility in December 2015. Review of a nurse's note, dated 4/27/21, indicated Resident #29 had complaints of discomfort to his/her left side of the face near the ear. The note indicated this nurse attempted to look inside of the Resident's mouth and noted that the area on the left side of the face was swollen and tender/painful to touch. The note indicated that a request was left for the physician to assess the area and to advise on how to proceed. Review of the clinical record did not indicate any follow up by the physician nor any further information about the area to the Resident's face. During an interview, on 8/19/21 at 12:50 P.M., the Director of Nurses (DON) said that she spoke with the Unit Manager about the 4/27/21 incident. The DON said that the Unit Manager saw the request for the physician to assess Resident #29 on 4/27/21, went to assess the Resident relative to the area on his/her left side of the face, and said she did not see anything concerning so she did not have the physician follow up. The DON said that the Unit Manager should have put in a progress note indicating what was done, but said that this did not occur.

Based on observation, interviews and policy review, the facility failed to ensure the environment remained free of accident hazards relative to smoking safety in the designated smoking area. Findings include: A review the facility policy titled, Resident Smoking Policy, revised on 8/1/18, indicated that protective equipment would be provided in the designated smoking location. This included: -Fire blanket -Safety ashtrays -Fire extinguisher -Call system A review of the current list of residents who smoke, provided to the surveyors by the facility upon entrance, indicated there was one resident who actively smoked cigerattes. During an observation and interview, on 8/18/21 at 1:55 P.M., the Staff Development Coordinator (SDC) and surveyor observed the smoking area. The surveyor did not observe a smoking blanket nor a fire extinguisher in or near the designated smoking area. The SDC said there was no fire extinguisher or fire blanket located outside in the designated area or inside near the designated smoking area, as required. During an interview, on 8/18/21 at 3:34 P.M., the Administrator said smoking safety items include, a smoking apron, a fire extinguisher and a smoking blanket, and the required missing items will be purchased.

Based on record reviews and interviews, the facility staff failed to accurately code Minimum Data Set (MDS) Assessments for 3 Residents (#8, #28 and # 30), out of a total sample of 18 residents. Findings include: 1. For Resident #8, the facility staff failed to code a Quarterly MDS Assessment for the use of an antidepressant. Resident #8 was admitted to the facility in 7/2018 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 3/1/19 indicated in Section N0410 that Resident #8 did not receive any antidepressants during the 7 day assessment period. Review of the 3/2019 Monthly Physician order [REDACTED]. During an interview on 4/11/19 at 2:46 P.M., the MDS Nurse said the 3/1/19 Quarterly MDS Assessment was miscoded indicating the Resident did not receive any antidepressants. 2. For Resident #28, the facility staff miscoded an Annual MDS Assessment relative to falls with major injury. Resident #28 was admitted to the facility in 1/2016. Review of the Annual MDS Assessment with an ARD of 1/4/19 indicated in Section 1900 that Resident #28 had 2 or more falls with major injury since the prior assessment. Review of the medical record did not indicate Resident #28 sustained any falls with major injury since the prior assessment. During an interview on 4/11/19 at 2:15 P.M., the MDS Nurse said the 1/4/19 Annual MDS Assessment was miscoded as the Resident did not sustain any falls with major injury since the prior assessment. 3. For Resident #30, the facility staff miscoded a Quarterly MDS Assessment for the use of an antianxiety medication. Resident #30 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment with an ARD of 1/11/19 indicated in Section N0410 that the Resident received antianxiety medication during the assessment period. Review of the medical record did not indicate an order for [REDACTED].>During an interview on 4/11/19 at 11:32 A.M., the MDS Nurse said the 1/11/19 Quarterly MDS Assessment was miscoded as the medical record did not contain a physician order [REDACTED].>

Based on interview and record review, the facility staff failed to ensure an Annual Minimum Data Set (MDS) Assessment was completed timely for 1 sampled Resident (#19), out of 18 sampled residents. Findings include: Resident #19 was admitted to the facility in 3/2018. Review of the Annual MDS Assessment, dated 3/22/19, indicated the following sections were left blank: B: Hearing, Speech, Vision C: Cognitive Patterns D: Mood E: Behavior F: Preferences for Customary Routines and Activities section Q: Participation in Assessment and Goal Setting Further review of the assessment indicated the Care Area Assessment (CAA) summary was incomplete and identified 7 care areas, but did not indicate the care planning decision within the 7 day time frame, as required. During an interview on 4/11/19 from 2:30-2:35 P.M., the MDS Nurse said the Annual MDS assessment dated [DATE] was not completed, as required. She said the assessment should have been completed and locked by 4/4/19.

Based on observations, record reviews and interviews, the facility staff failed to notify the physician of a change in condition for 2 residents (# 72 and # 49), out of a total sample of 18 residents. Findings include: Review of the facility Physician Notification Policy, dated 11/11/09 indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collecting and report to physician as indicated. If unable to contact attending physician, the Medical Director will be contacted. 1. For Resident #72, the facility staff failed to notify the physician of a change in bowel status. Review of the facility Bowel Management Protocol Policy, dated 11/11/13, indicated : All Nursing Staff are responsible for charting a resident's bowel movements in the Medical Record. Any resident who has not had a bowel movement in nine consecutive shifts or 3 full days, will have bowel protocol initiated. If bowel protocol is not effective, nurse will compete assessment: -Listen for bowel sounds in all 4 quadrants, -Check abdomen for firmness, distention, tenderness, rigidity, -Vital signs, -Assess for pain, nausea, vomiting. Nurse will call Medical Practitioner with assessment findings and results of bowel protocol. Medical Practitioner will provide new orders and nurse will carry out. Nursing documentation includes Medication Administration Record [REDACTED]. Nurse's notes should include bowel assessment and physician notification and response of the physician. Resident #72 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment with an Admission Reference Date (ARD) of 2/28/19 indicated the Resident had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Further review of the 2/2/919 Admission MDS Assessment indicated the Resident required extensive assistance of 2 person with transfer, toilet use and was continent of bowel. Review of the Point of Care (P[NAME]) documentation indicated Resident #72 had a small bowel movement on 2/28/19. The Resident's next documented bowel movement was on 3/6/19 (6 days later). Review of the medical record did not indicate the physician was notified of the Resident's bowel status. Further review of the P[NAME] documentation indicated the Resident had a bowel movement on 3/12/19 and on 3/21/19 (9 days later). Review of the medical record did not indicate the physician was notified of the Resident's bowel status. During an observation on 4/10/19 at 11:22 A.M., Resident #72 was sitting in a wheelchair in the unit dining room and was conversing with a visitor. During an interview on 4/12/19 at 12:49 P.M., Unit Manager (UM) #2 said the physician was not notified of the Resident's change in bowel status, as required. 2. For Resident #49, the facility staff failed to ensure the physician was notified when Resident #49 had a change in condition. Resident #49 was admitted to the facility in 9/2016. Review the Quarterly MDS Assessment, dated 11/2/18, indicated Resident #49 exhibited moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15. Review of the Anticoagulation care plan, dated 8/13/18, indicated Resident #49 was at risk for bleeding relative to anticoagulation therapy. The care plan included the following interventions: observe for signs/symptoms of bleeding including dark/tarry stools, hematuria and report any signs/symptoms of bleeding to the staff and physician immediately. Review of a nurses note, dated 1/7/19 at 2:45 P.M., indicated Resident #49 was extremely restless, agitated and was refusing food and medications. The nurse indicated the resident had one blood stained bowel movement and the health care proxy was updated on his/her condition. Review of a nurses note, dated 1/7/19 at 10:02 P.M., indicated Resident #49 was agitated, was toileted and had loose stools with scant amount of blood and mucous in his/her brief. The note further indicated the resident's health care proxy was in the facility earlier and notified of Resident #49's condition. Review of the clinical record did not indicate the physician was notified of Resident #49's change in condition. During an interview on 4/16/19 at 9:26-9:38 A.M., Unit Manager (UM) #1 said the nurses should have updated the resident's physician with the episodes of blood in his/her stool/brief, and that there was no indication that this occurred.

Based on interviews, record and policy reviews, the facility staff failed to conduct the State Nurse Aide Registry check timely for 1 out of 5 new hires, as required. Findings include: Review of the facility entitled Resident Abuse Prevention, Investigation and Reporting Policy, revised 2/17/17, indicated the following under Screening Procedures: -to assure sound hiring practices, the facility checks state nurse aide registry for all prospective employees (Massachusetts and other states in which the person is known to have worked) -documents the results of all screening activities On 4/11/19 at 2:47 P.M., the surveyor reviewed personal files of 5 newly hired employees at the facility. The review indicated that 1 employee, with a hire date of 1/15/19, had the state nurse aide registry check completed on 4/11/19 (3 months late). During an interview on 4/12/19 at 8:07 A.M., the Administrator said the state nurse aide registry checks are completed prior to hire. During a follow-up interview on 4/12/19 at 11:04 A.M., the Administrator said the nurse aide registry check was not completed timely for 1 employee (with a hire date of 1/15/19). He said it was missed during the hiring process and was completed on 4/11/19.

Based on observations, interviews and record reviews, the facility staff failed to ensure the plan of care was implemented for 3 sampled Residents (#19, #49 and #72), out of 18 sampled residents. Findings include: 1. For Resident #19, the facility staff failed to ensure the plan of care was followed relative to (a) ensuring the call bell was within reach and (b) failed to ensure the physician ordered diet was provided. Resident #19 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/21/18, indicated Resident #19 exhibited severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15, required assist of 1 person with transfers and ambulation and was on a therapeutic diet. a. Review of the Falls care plan, dated 6/27/18, indicated Resident #19 was at risk for falls and included the following intervention: keep call bell within reach. Review of the Activities of Daily Living (ADL) care plan, dated 9/11/18, indicated Resident #19 had an alteration in his/her ability to perform self care and included the following interventions: call light within reach and encourage resident to use. During an observation on 4/11/19 at 1:31 P.M., Resident #19 was lying in bed. The call bell was observed on the floor under the resident's bed, and was not accessible. During an observation and interview on 4/12/19 at 8:16 A.M., Resident #19 was lying in bed. The call bell was observed on the floor, under the resident's bed, and was not accessible. During an observation on 4/12/19 at 9:02 A.M., Resident #19 was observed in the bathroom located in his/her room. The call bell was observed on the floor, under the resident's bed, and was not accessible. Nurse #1 entered the resident's room during this observation. During an interview on 4/12/19 at 9:02 A.M., Nurse #1 said Resident #19 would not have been able to access his/her call bell because it was on the floor under the bed. b. Review of the Nutrition care plan, dated 1/12/19, indicated Resident #19 was on a No Added Salt (NAS) diet and a fluid restriction and included the following intervention: provide diet as ordered-NAS Regular with 1600 milliliter(ml) fluid restriction. Review of a physician's interim/telephone order, dated 2/11/19, indicated an order to discontinue Resident#19's fluid restriction. Review of the 4/2019 physician's orders [REDACTED]. On 4/12/19 at 9:02 A.M., Resident #19's breakfast tray was observed on the overbed table next to his/her bed. The meal ticket indicated Resident #19 was on a 1600 ml fluid restriction. During an interview on 4/12/19 at 9:07 A.M., Nurse #1 said Resident #19 was on a fluid restriction and received 360 mls with each meal, and his/her fluid intake was monitored by the staff. During an interview on 4/12/19 at 9:10 A.M., Unit Manager (UM) #1 said Resident #19 was no longer on a fluid restriction. She said it was discontinued by the physician 2. For Resident #49 the facility staff failed to ensure the physician's orders [REDACTED]. Resident #49 was admitted to the facility in 9/2016 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 2/1/19, indicated Resident #49 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, and required supervision with eating. Review of the physician's interim/telephone order, dated 4/11/19, indicated an order for [REDACTED]. Review of the Nutrition care plan, dated 4/11/19, indicated Resident #49 had weight loss, a decline in intake and was no longer wearing dentures. The following interventions were included: provide mechanical soft diet. Review of the resident profile, updated 4/11/19, indicated the following: assist of 1 staff with meals in the supervised dining room, provide mechanical soft diet with puree fruits and vegetables and bread products allowed. Review of the 4/2019 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During an observation on 4/16/19 at 8:25 A.M., Resident #49 was seated in a geriatric chair in the supervised dining room with other residents. Certified Nursing Assistant (CNA) #3 set up Resident #49's breakfast tray which included a danish, scrambled eggs and a whole banana. CNA #3 was observed to slice the banana on the plate and walk away. At 8:31 A.M., CNA #2 was observed to assist Resident #49 with breakfast. The surveyor observed CNA #2 take a banana slice and put it into Resident #49's mouth. At this time, the surveyor asked to review the meal ticket, which indicated a mechanical soft diet with puree fruits and vegetables. CNA #2 said the resident's diet was recently changed and he/she could have soft foods, like the banana. During an interview on 4/16/19 at 8:31 A.M., Nurse #2 said Resident #49's diet had recently been changed. She said foods needed to be ground and items like fruits and vegetables needed to be pureed. Nurse #2 said the resident should not have bananas unless they were pureed. During an interview on 4/16/19 at 10:36 A.M., the Dietitian said Resident #49's diet order indicated for him/her to receive ground meats, pureed fruits and vegetables and soft breads. She further said the resident should not have received the banana with breakfast unless it was pureed. 3. For Resident #72, the facility staff failed to develop and implement a plan of care relative to bowel management. Resident #72 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment with an Admission Reference Date (ARD) of 2/28/19 indicated the Resident had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the BIMS Assessment. Further review of the 2/2/919 MDS Assessment indicated the Resident required extensive assistance of 2 persons with transfer and toilet use and was continent of bowel. Review of the 3/2019 Monthly Physician order [REDACTED]. If no results from MOM, give [MEDICATION NAME] (laxative)suppository, 10 mg, one rectally as needed for constipation-unless [MEDICAL TREATMENT] resident. If no results from the [MEDICATION NAME] suppository, give Fleets enema (used as a laxative to promote bowel movement or to relieve constipation) one rectally as needed, if no results from the Fleets, notify Medical Doctor (MD). Review of the medical record indicated the Resident did not have regular bowel movements as evidenced by Point of Care (P[NAME]) documentation indicating Resident #72 had a bowel movement on 2/28/19, 3/6/19, 3/12/19 and 3/21/19. Review of the 4/1/19 Nurse Note indicated the Resident was having impacted stool and manual stimulation was provided by staff. Extra large hard stools were expelled, causing the Resident pain. Review of the medical record did not show any evidence that the bowel protocol was followed, as ordered. During an interview on 4/12/19 at 12:49 P.M., UM #2 said the facility staff did not follow the plan of care for bowel management for Resident #72.

Based on record review, observation and interview, the Facility failed to ensure that 1 of 8 residents with falls (#2) received adequate supervision and assistance devices to prevent accidents, with 1 fall resulting in a laceration that required sutures, in a total sample of 15 residents. Findings include: Resident #2 was admitted to the Facility in 2/2014 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], indicated that the resident had severe cognitive loss, with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. The resident required extensive assist with transfers, toilet use, hygiene, bathing and dressing, did not ambulate, was incontinent of bladder, and had no falls. The Care Area Assessment (of 2/20/14) indicated that the resident was at risk for falls due to a history of falls, decreased functional abilities, and confusion with poor safety awareness due to dementia. Review of the Falls Care Plan indicated the following: Educate family on fall prevention strategies. Provide well lit, uncluttered environment. Place items resident uses frequently in reach to prevent bending or reaching. Gait belt for all transfers. Encourage participation in diversional activities. Encourage use of proper footwear. Keep bed in low position. Bed alarm while in bed. Scoop mattress to bed. Use wheelchair as primary mode of mobility. The quarterly Minimum Data Set (MDS) assessment of 8/15/14 indicated that the resident had short and long term memory loss and had moderately impaired decision making skills - decisions poor; cues/supervision required. The resident had 2 or more falls since the prior assessment. Review of Nurse's Notes and Post Fall Investigation indicated that on 8/29/14 at 9:00 A.M., another resident propelled his/her wheelchair to the dayroom and reported to staff, that a resident was falling out of his/her wheelchair. The nurse found Resident #2 in the hallway on his/her hands and knees, in front of the wheelchair. There was a Tabs alarm in the wheelchair, but there was no indication that it sounded. New interventions included: pressure pad alarm in wheelchair. Review of the Nurses' notes indicated that Resident #2 sustained three falls in the bedroom, on 6/16/14,7/28/14 and 7/28/14 with no injuries. Review of Nurse's Notes and Post Fall Investigation indicated that on 11/9/14 at 1:50 P.M., the wheelchair alarm sounded, Resident #2 was found on the floor in his/her bedroom. The resident sustained [REDACTED]. New interventions included: if resident refuses a nap, bring out of bedroom to common area, and Velcro alarming seatbelt. Review of Nurse's Notes and Post Fall Investigation indicated that on 12/25/14 at 10:00 P.M., Resident #2 was heard yelling, Help. Resident #2 was found lying on the bathroom floor, bleeding from the forehead. The Certified Nursing Assistant (CNA) had transferred the resident onto the toilet. The resident requested privacy, and the CNA left the resident alone in the bathroom (even though the resident utilized a Velcro alarming seatbelt in the wheelchair, utilized a bed alarm, was impulsive, had poor balance, had severe cognitive loss, and a history of falls). In addition, the CNA left the bedroom to assist another resident. Resident #2 was sent to the emergency room via ambulance and received 2 sutures to the forehead. During an observation on 6/10/15 at 11:20 A.M., Resident #2 was found sitting in a wheelchair in his/her bedroom, with a visitor. The Velcro alarming seatbelt was in place. During an observation on 6/11/15 at 9:00 A.M., Resident #2 was found sitting in a wheelchair in the hallway to the dayroom. The Velcro alarming seatbelt was in place. The resident was leaning forward and attempting to place a half full cup of water on a bedside table that was out of reach. During an interview on 6/15/15 at 8:45 A.M., Unit Manager #1 said, regarding the fall of (12/25/15), that Resident #2 had requested privacy while sitting on the toilet; and the CNA left the resident's bathroom and bedroom. Unit Manager #1 said that the CNA should have stood just outside the bathroom door with the door ajar. Unit Manager #1 said that if the CNA didn't know what to do, she should have asked the nurse. During an interview on 6/15/15 at 8:55 A.M., the Director of Nurses said that the CNA involved and other nursing staff had been educated. Review of the Inservice Program (of 12/26/14) indicated the following: Summary of Content - Any resident who has an alarm of any kind is never to be left alone on the toilet.