Every finding on record at Linden Ponds

Based on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident or Family Group Meeting, dated as revised February 2022, indicated but was not limited to:The group approved staff person:-Types up group meeting minutes and distributes to department heads as applicable.-If any concerns are conveyed in the resident group meeting, department heads respond to the group approved designated staff member within 2 weeks with a written action plan.-Action plans and minutes are submitted to the Administrator for signature. Review of January 2026 Resident Council Minutes, dated 1/14/26, indicated but was not limited to:-Food is mediocre and residents would like more variety of proteins and desserts-Aides should have their names in large print letters on the front of their shirts because residents could not identify them-Residents would like music in the living room-Concern with missing laundry items Review of February 2026 Resident Council Minutes, dated 2/4/26, indicated but was not limited to:-Food is mediocre and residents would like more variety of proteins and desserts-Residents would like music in the living room Review of the March 2026 Resident Council Minutes, dated 3/26/26, indicated but was not limited to:-Some of the Certified Nursing Assistants (CNA) do not talk to the residents while providing care Further review of the January, February, and March 2026 Resident Council Minutes failed to indicate any action plans had been submitted and failed to include feedback provided to the residents. During a group meeting held on 4/29/26 at 10:40 A.M., the surveyor met with 11 residents during a Resident Council Meeting. The following concerns were voiced:-Complaints brought up during Resident Council Meetings were not addressed and therefore unresolved.-In most cases there was no follow-up to the concerns brought up during their monthly meetings and they would like feedback on the concerns brought forward.-Resident #3 stated he/she had brought up concerns regarding a lack of medical care at the February meeting, and he/she never received any follow up.-Resident # 35 said the lack of follow up is common and you need to have a big mouth if you want anyone to follow up. During an interview on 4/29/26 at 11:45 A.M., Senior Programmer #1 (SP #1) and Senior Programmer #2 (SP #2) said they are the designated staff members responsible for assisting the residents with arranging their monthly council meetings and staying with the residents during the meetings. SP #2 said at the conclusion of the meetings she types up the minutes and then stores them on a shared drive that can be accessed by the other staff members. SP #2 said the notes are not distributed to department heads. SP #1 and SP #2 said they do not follow up with department heads regarding concerns brought forward but if there were any significant concerns they would alert their Program Manager (PM). SP #1 and SP #2 said they did not know what happens with the concerns once they alert the PM. They said they did not receive follow up on the concerns and they did not report back to the Resident Council at the next meeting regarding the concerns brought forward at the previous meeting. During an interview on 4/29/26 at 11:58 A.M., the PM said the follow-up she has done from Resident Council concerns had been verbal communication with other department heads. When asked specifically about the follow-up from the food concerns raised in January and February, she said she could not recall what the specific follow-up was. The PM was unable to provide the surveyor with any action plans. During an interview on 4/29/26 at 3:05 P.M., the Administrator stated she was not aware that SP#1 and SP #2 were not following up with the Resident Council regarding issues brought forward at the previous meeting. She stated her expectation is that if a group concern is brought up at a meeting there would be follow-up provided at the next meeting.

Based on observation, interviews, and record review, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections for two Residents (#14 and #3), out of a total sample of 17 residents. Specifically, the facility failed:1. For Resident #14, to implement Contact Precautions (infection control measures used to prevent the spread of infection through direct or indirect contact with residents or contaminated surfaces); and2. For Resident #3, to implement Enhanced Barrier Precautions (EBP, infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms (MDROs) in nursing homes) when providing Foley catheter care.Findings include:Review of the facility's policy titled Infection Prevention and Control: Preventing Transmission of Infectious Agents, dated 10/2022, indicated, but was not limited to, the following:-Staff will follow appropriate precautions in order to prevent the transmission of infectious agents.-Transmission-Based Precautions are for employees and residents who are known or suspected to be infected or colonized with infectious agents, including certain epidemiological pathogens, which require additional control measures to effectively prevent transmission. -Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) in skilled-nursing/long-term care and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for MDROs to transfer to staff hands and clothing.-Transmission-Based Precautions include:Contact Precautions: Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. -Enhanced Barrier Precautions may be used during high contact resident activities for those residents considered high risk for MDROs such as:*Infection or colonization with an MDRO when Contact Precautions do not otherwise apply.*Wounds and/or indwelling medical devices (eg. Urinary catheter).Review of the Centers for Disease Control and Prevention (CDC) Contact Precautions sign indicated providers and staff must: put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit, use dedicated disposable equipment and clean and disinfect reusable equipment before use on another person.Review of the CDC Enhanced Barrier Precautions sign indicated providers and staff must wear gloves and a gown for high-contact resident care activities, including: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care.1. Resident #14 was admitted to the facility in October 2021 with diagnoses including psoriasis (a chronic skin disease characterized by itchy, scaly patches on the skin), dementia, and skin abscess (a skin infection).Review of Resident #14's Minimum Data Set (MDS) assessment, dated 2/16/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #14's Care Plan indicated, but was not limited to, the following:-Positive (+) MRSA and MDRO Proteus mirabilis (a bacteria primarily associated with urinary tract infections) left buttock-Maintain Contact Precautions-3/23/26 Erythromycin 250 every 6 hours x14 days superimposed cellulitis related to psoriasis. Maintain contact precautions.-4/13/26 Continue Contact Precautions due to ongoing psoriatic plaque treatment (tx) and intertrigo flareReview of Resident #14's Progress Notes, indicated, but was not limited to, the following:-2/2/26: Resident cultures continue to be pending - aerobic showing Methicillin-Resistant Staphylococcus aureus (MRSA, a type of bacteria that causes skin infections and is resistant to many antibiotics), placed on contact precautions. -2/3/26: Resident's wound was cultured and resulted positive for MRSA and MDRO.Review of Resident #14's Wound Culture report for specimen obtained 1/28/26 indicated the wound culture grew out bacteria including Veilonella dispar (a bacteria normally found in the oral cavity, gastrointestinal tract, and genitourinary tract in humans but can become pathogenic in some individuals), Multi-Drug Resistant Proteus mirabilis, MRSA, and Enterococcus faecalis (a bacteria normally found in the gastrointestinal tract that is capable of causing serious infections). The surveyor made the following observations:-4/28/26 at 8:29 A.M.: CDC Contact Precautions sign posted outside of Resident #14's room with a PPE storage cart located below-4/28/26 at 9:06 A.M.: Certified Nursing Assistant (CNA) #1 in Resident #14's room assisting the Resident with breakfast. CNA #1 was not wearing any PPE.-4/28/26 at 9:09 A.M.: Activities Assistant #3 entered Resident #14's room. Activities Assistant #3 did not perform hand hygiene or don (put on) PPE when entering the room.-4/28/26 at 9:17 A.M.: CNA #1 in Resident #14's room sitting in a chair beside the Resident's bed. CNA #1 was not wearing any PPE.-4/28/26 at 11:58 A.M.: CNA #1 in Resident #14's room assisting the Resident in completing his/her dining order. CNA #1 was not wearing any PPE. -4/29/26 at 8:35 A.M.: Contact precautions sign posted outside of Resident #14's room with PPE storage cart located below.-4/29/26 at 9:44 A.M.: CNA #5 in Resident #14's room assisting the Resident with breakfast. CNA #5 was not wearing any PPE.-4/29/26 at 10:22 A.M.: CNA #5 in Resident #14's room assisting the Resident with morning activities of daily living. CNA #5 was not wearing any PPE.-4/19/26 at 11:50 A.M.: Nurse #1 and CNA #5 in Resident #14's room. Nurse #1 and CNA #5 were not wearing any PPE.During an interview on 4/28/26 at 11:54 A.M., CNA #1 said Resident #14 required Contact Precautions and that staff should wear gloves and gowns when providing care.During an interview on 4/28/26 at 11:58 A.M., Nurse #1 said Resident #14 required Contact Precautions but she was not sure why. Nurse #1 said staff needed to wear gloves and gowns only when providing care.During an interview on 4/28/26 at 3:58 A.M., the Director of Nursing (DON) said Resident #14 had had a MRSA-positive abscess and had multiple psoriatic lesions and required Contact Precautions. During an interview on 4/29/26 at 12:04 P.M., Resident #14 said some of the staff wore gowns and gloves when providing care, but some of the staff did not. During a follow-up interview on 4/30/26 at 9:16 A.M., the DON said it was her expectation that all staff implement Contact Precautions and don PPE when entering Resident #14's room.2. Resident #3 was admitted to the facility in June 2025 with diagnoses including history of bladder cancer and urinary retention. Review of Resident #3's MDS assessment, dated 1/26/26, indicated Resident #3 was moderately cognitively impaired as evidenced by a BIMS score of 12 out of 15. Further review of the MDS assessment indicated Resident #3 had an indwelling urinary catheter. Review of Resident #3's Physician's Orders indicated, but was not limited to, the following:-Indwelling urinary Foley: Maintain Enhanced Barrier Precautions due to Foley catheter (order date 10/15/25)The surveyor made the following observations:-4/28/26 at 10:15 A.M.: EBP sign hanging outside Resident #3's room with a PPE storage cart located below. CNA #1 came from the bathroom in Resident #3's room to the doorway of the room, where a trolley containing a trash container was located. CNA #1 was wearing gloves and carrying a urinary catheter drainage bag containing a small amount of yellow urine and disposed of the drainage bag in the trash container. CNA #1 said she was assisting Resident #3 with a shower at that time. The surveyor did not observe CNA #1 wearing a gown.During an interview on 4/28/26 at 11:54 A.M., CNA #1 said Resident #3 no longer required EBP anymore.During an interview on 4/30/26 at 9:16 A.M., the DON said it was her expectation that all staff implement EBP when providing high-contact care to Resident #3.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose individualized comprehensive plan of care and resident care card, indicated interventions included that two staff members were required to provide assistance with bathing, dressing and bed mobility, the facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when on 01/14/26, Care Associate #1 provided care and repositioned Resident #1 without another staff member present to assist her, Resident #1 slid off the bed, and landed face down on the floor and was noted to be bleeding from a laceration on his/her forehead. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required seven sutures to close the wound. Findings Include: Review of the Facility's Policy titled, Care/Service Plans, dated 05/2021, indicated the following:-each guest/resident will have an individualized care/service plan developed; care/service plans will include resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs;-a comprehensive person-centered care plan will be developed by the Interdisciplinary Team (IDT) and will include measurable objectives, preferences, goals, any specialized services as a result of the Preadmission Screening and Annual Resident Review (PASARR) evaluation, resident's discharge plan and will address the resident's medical, nursing, mental and psychosocial needs as identified from the resident's comprehensive assessment;-care plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly review assessments;Review of the Facility's Policy titled, Care Card, undated, indicated the following:-each resident will have a care card, a quick summary of their unique direct care needs, in alignment with the care plan; the care card provides specific information on the resident's mobility, transfer, nutrition, cognition, elimination and additional care needs.-each care card will be revised alongside the care plan to reflect any status change and will be reviewed at designated intervals as a minimum based on service line (skilled nursing).-care card - a quick reference summary of common specific resident care needs.-the care card when printed will be placed in front of the resident's care plan/service plan in the resident's room for ease of access to all employees.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 01/21/26, indicated that on 01/14/26 at 7:00 A.M., a Care Associate (identified as Care Associate #1) was assisting Resident #1 with dressing while he/she was in bed. The Report indicated that when Care Associate #1 pulled on Resident #1' s pants, he/she slid off the bed and landed on the floor. The Report indicated that Care Associate #1 called for help, the nurse arrived and immediately assessed Resident #1.The Report further indicated that Resident #1 was found face down on the floor bleeding from the right side of his/her anterior (front) head, he/she had sustained a laceration above his/her right eyebrow, the medical provider was notified and Resident #1 was transferred to ED for evaluation and treatment.Resident #1 was admitted to the Facility in October 2024, diagnoses included dementia, cerebrovascular accident (stroke), hemiparesis of right side (weakness), osteoarthritis, coronary artery disease, atrial fibrillation (irregular heartbeat), hypertension, hyperlipidemia, and muscle weakness.Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 00 (severe impaired cognition) and was dependent on staff with bathing, dressing and bed mobility. Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), dated 01/09/26, indicated that he/she required total dependence of two staff members with bathing, dressing and bed mobility. Review of Resident #1's Resident Care Card, (used as a reference guide by Care Associates aka, Certified Nurse Aide's, provides direct care staff with a brief overview of each resident's care needs), reviewed and updated with his/her plan of care, indicated that he/she required total dependence of two staff members with bathing, dressing and bed mobility. Review of Resident #1's Nurse Progress Note, dated 01/14/26, (written by Nurse #1) indicated that she heard a Care Associate (identified as Care Associate #1) shouting for help, upon approaching Resident #1's room he/she was observed to be face down on the floor and there was notable bleeding from the anterior right side of his/her head. The Note indicated that upon assessment, Resident #1's had a laceration above his/her right eyebrow, pressure was applied to the area, emergency protocols were initiated and Resident #1 was transported to the Hospital ED for further evaluation. The Note further indicated Care Associate #1 stated that she was turning Resident #1 while providing personal care and he/she fell and hit his/her head on the floor.During a telephone interview on 02/17/26 at 3:53 P.M., (which included review of her written statement) Nurse #1 said that on 01/14/26 around 7:00 A.M she heard one of the Care Associates (identified as Care Associate #1) shout out, I need help and said she proceeded towards the shouting which was coming from Resident #1's room. Nurse #1 said upon entering the room she saw Resident #1 lying face down on the floor near his/her bed. Nurse #1 said Resident #1 was bleeding profusely from his/her head and said she noted that he/she had sustained a laceration above his/her right eyebrow. Nurse #1 said she applied pressure to the area on Resident #1's head, had Care Associate #1 stay with him/her while she went to call 911 and said he/she was transported to the Hospital ED for evaluation and treatment.Nurse #1 said she asked the Care Associate #1 what happened and said Care Associate #1 told her that she turned Resident #1 while providing care, he/she slid off the bed and hit his/her head on the floor. Nurse #1 said Resident #1 required assistance of two staff members for bed mobility and personal care while in bed. Nurse #1 said when she entered Resident #1's room that morning Care Associate #1 was the only staff member in his/her room at the time.During a telephone interview on 02/18/26 at 10:01 A.M., (which included review of her written statement) Care Associate #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/14/26 and was assigned to provide care to Resident #1. Care Associate #1 said that she was very familiar with the care Resident #1 required because she was assigned to him/her on the days she was scheduled to work. Care Associate #1 said she has worked at the Facility for two years and has been a Certified Nurse Aide for 15 years. Care Associate #1 said residents' care cards are located in their rooms and said staff are supposed to look at a resident's care card before providing care to any resident. Care Associate #1 said she knew that Resident #1 required two staff members with bed mobility and while doing care while in bed, but said she provided care to Resident #1 by herself that day (01/14/26). Care Associate #1 said while she was turning Resident #1 to try to put his/her pants on, he/she slid out of bed and fell face down on the floor. Care Associate #1 said she did not ask another staff member to help her with Resident #1's care and she did not follow the interventions identified on his/her care card but said she should have.Review of the Hospital ED Notes and After Visit Summary, dated 01/14/26, indicated that Resident #1 presented to the ED after a fall at the facility, he/she sustained a laceration that was 2.5 centimeters (cm) in length to his/her right forehead, and the wound was repaired (closed) with seven sutures. During an interview on 02/11/26 at 3:59 P.M. the Director of Nursing (DON) said Resident #1 required assistance of two staff members with bathing, dressing and bed mobility which was indicated on his/her care plan and resident care card.The DON said that Care Associate #1 provided care to Resident #1 by herself, he/she slid off the bed onto the floor, he/she sustained a laceration to the upper right side of his/her forehead, and he/she required sutures to close the laceration. The DON said Care Associate #1 did not follow interventions from Resident #1's care plan, his/her resident care card or the Facility's policies.The DON said it is her expectation that all nursing staff check resident's care plans and care cards prior to providing care to a resident and that they follow the Facility's policies.On 02/11/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of 01/20/26, which addressed the area(s) of concern as evidenced by:A. On 01/14/26, Resident #1 returned to the Facility with seven sutures and new orders that included: to remove sutures in ten days, monitor his/her laceration for signs and symptoms of infection including worsening pain, selling, redness or discharge and continue pain management as ordered.B. On 01/16/26, Physical therapy evaluated Resident #1 and recommended a wider bariatric size mattress to assist with bed mobility and his/her bed was repositioned with the headboard against the wall.C. On 01/16/26, Nursing staff updated Resident #1's care plan and care card to reflect the new interventions recommended by the Physical Therapist.D. On 01/20/26, the Nursing Administration completed a full house audit of all residents' care plans, and care cards to ensure they were accurate, up to date and located in resident's rooms on all units.E. On 01/19/26, the Staff Development Coordinator initiated mandatory education for, all nursing staff on care plans, care cards, lifts, transfers, and bed mobility (which include resident safety during care), as well as facility policies and procedures.F. The Director of Nursing and/or designee will conduct random audits on resident's care plans and care cards for accuracy and location weekly for one month, then monthly for two months or until overall compliance is achieved. G. The Concern Area was discussed by the QAPI Committee, results of the audits will continue to be presented and reviewed at the monthly QAPI Committee meetings for three months or until compliance is achieved.H. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members with bathing, dressing and bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during care in an effort to maintain his/her safety and prevent an incident/accident resulting in an injury. On 01/14/26, Care Associate #1 provided care and repositioned Resident #1 without another staff member present to assist her, Resident #1 slid off the bed, and landed face down on the floor. Resident #1 was observed to be bleeding from a laceration on his/her forehead, was transferred to the Hospital Emergency Department (ED), where he/she required seven sutures to close the wound.Findings include: Review of the Facility's Policy titled, Fall Management, dated 04/2023, indicated the following: -to minimize and/or decrease the risk for falls through an interdisciplinary review of resident and to develop individualized care/service plan approaches;-fall: any event resulting in the resident coming to rest unintentionally on the floor or other lower level but not as a result of an overwhelming external force;-when a resident is found on the floor, a fall is considered to have occurred;-each resident will be assessed using the holistic assessment for potential risk for falls;-resident identified with 1 or more risks will be considered at risk for falls and the falls prevention protocols will be initiated;-care/service plan will be developed using individualized approaches identified during assessment process;Review of the Facility's Policy titled, Lifting, Transfer and Bed Mobility, dated 02/2026, indicated the following: -the purpose of this program is to identify and assess the residents in continuing care that require mobility assistance to eliminate unnecessary manual repositioning and lifting resulting in potential injury or increase pain/discomfort to guest/resident.-bed mobility will be assessed as one (1) person assist or two (2) or more person assist.-each resident's care or service plan will address care approaches if a mobility need is identified to include type of lift, sling size and approaches to comfort guest/resident during transfer or repositioning in bed.-type and level of assistance required for a resident's transfer mobility will be communicated to staff and reflected in the care/service plan; information will include device to be utilized, number of staff required for bed mobility and/or transferring assistance.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 01/21/26, indicated that on 01/14/26 at 7:00 A.M., a Care Associate (identified as Care Associate #1) was assisting Resident #1 with dressing while he/she was in bed. The Report indicated that when Care Associate #1 pulled on Resident #1's pants, he/she slid off the bed and landed on the floor. The Report indicated Care Associate #1 called for help, the nurse arrived and immediately assessed Resident #1.The Report further indicated that Resident #1 was found face down on the floor bleeding from the right side of his/her anterior (front) head, he/she had sustained a laceration above his/her right eyebrow, the medical provider was notified and Resident #1 was transferred to ED for evaluation and treatment.Resident #1 was admitted to the Facility in October 2024 diagnoses included dementia, cerebrovascular accident (stroke), hemiparesis of right side (weakness), osteoarthritis, coronary artery disease, atrial fibrillation (irregular heartbeat), hypertension, hyperlipidemia, and muscle weakness.Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 00 (severe impaired cognition) and was dependent on staff with bathing, dressing and bed mobility. Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), dated 01/09/26, indicated that he/she required total dependence with assistance of two staff members with bathing, dressing and bed mobility. Review of Resident #1's Resident Care Card, (used as a reference guide by Care Associates/Certified Nurse Aide's, provides direct care staff with a brief overview of each resident's care needs), reviewed and updated with his/her plan of care, indicated that he/she required total dependence with assistance of two staff members with bathing, dressing and bed mobility. Review of Resident #1's Nurse Progress Note, dated 01/14/26, (written by Nurse #1) indicated that Nurse #1 heard a Care Associate (identified as Care Associate #1) shouting for help, upon approaching Resident #1's room he/she was observed to be face down on the floor and there was notable bleeding from the anterior right side of his/her head. The Note indicated that upon assessment, Resident #1's head laceration above his/her right eyebrow was bleeding, pressure was applied to the area, emergency protocols were initiated and Resident #1 was transported to the Hospital ED for further evaluation. The Note Further indicated Care Associate #1 stated that she was turning Resident #1 while providing personal care, he/she fell out of bed and hit his/her head on the floor.During a telephone interview on 02/17/26 at 3:53 P.M., (which included review of her written statement) Nurse #1 said that on 01/14/26 around 7:00 A.M she heard Care Associate #1 shout out, I need help and said she proceeded towards the shouting coming from Resident #1's room. Nurse #1 said upon entering the room she saw Resident #1 lying face down on the floor near his/her bed. Nurse #1 said Resident #1 was bleeding profusely from his/her head and said she noted that he/she had sustained a laceration above his/her right eyebrow. Nurse #1 said she applied pressure to the area on Resident #1's head, had Care Associate #1 stay with him/her while she went to call 911 and said he/she was transported to the Hospital ED for evaluation and treatment.Nurse #1 said she asked Care Associate #1 what happened and said Care Associate #1 told her that she when turned Resident #1 while providing care, he/she slid off the bed and hit his/her head on the floor. Nurse #1 said Resident #1 required assistance of two staff members for bed mobility and personal care while in bed. Nurse #1 said when she entered Resident #1's room that morning Care Associate #1 was the only staff member in his/her room at the time.During a telephone interview on 02/18/26 at 10:01 A.M., (which included review of her written statement) Care Associate #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/14/26 and was assigned to provide care to Resident #1. Care Associate #1 said that she was very familiar with the care Resident #1 required because she was assigned to him/her on the days she was scheduled to work. Care Associate #1 said she has worked at the Facility for two years and has been a Certified Nurse Aide for 15 years. Care Associate #1 said that while providing morning care to Resident #1, she turned him/her on his/her back then put his/her pants on up to his/her ankles. Care Associate #1 said she turned Resident #1 towards her near the edge of the bed, then as she started to pull up his/her pants, he/she slid off the bed, and landed on the floor face down. Care Associate #1 said that Resident #1 hit his/her head on the floor and was bleeding from above his/her right eyebrow. Care Associate #1 said she immediately applied pressure with a towel to the area on Resident #1's forehead and yelled out, I need help.Care Associate #1 said she knew that Resident #1 required two staff members with bed mobility and care while in bed, but said she provided care to Resident #1 by herself that day (01/14/26). Care Associate #1 said she did not ask another staff member to help her with Resident #1's care, but she should have.Review of the Hospital ED Notes and After Visit Summary, dated 01/14/26, indicated that Resident #1 presented to the ED after a fall at the facility, he/she sustained a laceration that was 2.5 centimeters (cm) in length to his/her right forehead, and the wound was repaired (closed) with seven sutures. The Summary further indicated care instructions that included: to remove sutures in ten days and monitor for signs and symptoms of infection including worsening pain, selling, redness or discharge.During an interview on 02/11/26 at 3:59 P.M. the Director of Nursing (DON) said she was notified on 01/14/26 that Resident #1 had a fall and he/she was sent to the Hospital ED. The DON said Resident #1 required assistance of two staff members with bathing, dressing and bed mobility which was indicated on his/her care plan and resident care card.The DON said that Care Associate #1 provided care to Resident #1 by herself, he/she slid off the bed onto the floor, he/she sustained a laceration to the upper right side of his/her forehead, and he/she required sutures to close the laceration. The DON said Care Associate #1 did not follow Resident #1's care plan. resident care card or the Facility policy.The DON said it is her expectation that all nursing staff check resident's care plans and care cards prior to providing care to ensure the resident is provided with the necessary level of staff assistance to meet their care needs, as well as maintaining resident and staff member safety. On 02/11/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of 01/20/26, which addressed the area(s) of concern as evidenced by:A. On 01/14/26, Resident #1 returned to the Facility with seven sutures and new orders that included: to remove sutures in ten days, monitor his/her laceration for signs and symptoms of infection including worsening pain, selling, redness or discharge and continue pain management as ordered.B. On 01/16/26, Physical therapy evaluated Resident #1 and recommended a wider bariatric size mattress to assist with bed mobility and his/her bed was repositioned with the headboard against the wall.C. On 01/16/26, Nursing staff updated Resident #1's care plan and care card to reflect the new interventions recommended by the Physical Therapist.D. On 01/20/26, the Nursing Administration completed a full house audit of all residents' care plans, and care cards to ensure they were accurate, up to date and located in resident's rooms on all units.E. On 01/19/26, the Staff Development Coordinator initiated mandatory education for, all nursing staff on care plans, care cards, lifts, transfers, and bed mobility (which include resident safety during care), as well as facility policies and procedures.F. The Director of Nursing and/or designee will conduct random audits on resident's care plans and care cards for accuracy and location weekly for one month, then monthly for two months or until overall compliance is achieved. G. The Concern Area was discussed by the QAPI Committee, results of the audits will continue to be presented and reviewed at the monthly QAPI Committee meetings for three months or until compliance is achieved.H. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who, on 03/20/25, reported that he/she had been physically abused by Certified Nurse Aide #1, the Facility failed to ensure Administration reported the reasonable suspicion of a crime, when although the Administrator was aware on 03/20/25, the facility did not notify local law enforcement until 04/15/25, the day of survey. Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigation, dated as revised May 2021, indicated that each staff member must report any actual/known, suspected, or alleged incident of physical abuse, neglect, or financial abuse, abandonment or isolation to his/her supervisor and/or other community leadership immediately. This includes incidents/actions that the staff member observes, suspects, or is informed of by a resident. Under the Elder Justice Act, staff in the nursing home have an additional responsibility to report incidents to the state agency and law enforcement. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 03/20/25, indicated that Resident #1 reported to CNA #2 that CNA #1 hit him/her. Review of the Facility's Investigation Report, undated, indicated that on 03/20/25, Resident #1 reported to CNA #2 that CNA #1 hit and punched him/her all over. The Facility's Investigation Report indicated that CNA #2 said she and CNA #1 transferred Resident #1 and said Resident #1 told her (CNA #2) that CNA #1 is a bitch and she had hit him/her. The Facility's Investigation Report indicated that nursing performed a skin check and found three small bruises on Resident #1's right thigh. The Facility's Investigation Report indicated that CNA #1 was terminated based on the findings of the Facility's Investigation, and that the Police had not been notified of Resident #1's abuse allegation. Resident #1 was admitted to the Facility in August of 2024, diagnoses included Alzheimer's Disease, agitation, and depression. Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 02/07/25, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. During an interview on 04/15/25 at 11:45 A.M., CNA #2 said that on 03/20/25 in the morning, CNA #1 helped her (CNA #2) transfer Resident #1 with the mechanical lift from his/her bed to his/her wheelchair. CNA #2 said that after CNA #1 left the room, Resident #1 told her (CNA #2) that CNA #1 was a bitch and that she hits him/her. CNA #2 said she reported the allegation it to Nurse #2 immediately. During a telephone interview on 04/23/25 at 9:36 A.M., Nurse #2 said that on 03/20/25, CNA #2 reported to her that Resident #1 told her that CNA #1 hit him/her (Resident #1). Nurse #2 said she went to Resident #1's room and said he/she (Resident #1) told her (Nurse #2) that CNA #1 had hit him/her, but did not know where on his/her body. Nurse #2 said she immediately reported Resident #1's allegation of physical abuse to Administration. During an interview on 04/15/25 at 3:03 P.M., the Administrator said that on 03/20/25, Nurse #2 notified her that Resident #1 had reported that CNA #1 had physically abused him/her. The Administrator said she immediately suspended CNA #1 and then terminated her, based on the findings of their investigation. The Administrator said she had not notified local law enforcement of the allegation of physical abuse until 04/15/25 (day of the survey).

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in six Residents' (58, #21, #2, #61, #20, and #267) rooms. Findings include: Review of the facility's policy titled Storage of Medication Administration, Receipt, Storage and Disposal, revised 10/23, indicated but was not limited to the following: -Medication Management in Continuing Care (CC) will include ordering, transcribing, receiving, proper storage, accurate documentation and safe administration of a residents' medications by authorized staff, consistent with state requirements. Receipt of Medications from Pharmacy Courier: -The Licensed nurse or Certified Medicine Aide/Tech (CMA/CMT) will place medications in the medication room on the neighborhood and medications will be placed in the resident medication cabinet or overflow medication. On 2/21/25 at 10:26 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #58's room: -A box of Lidoderm 4% patches (pain patch). On 2/21/25 at 10:37 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #21's room: -Two boxes of Albuterol sulfa (bronchodilator) 92.5 milligrams (mg)/3milliliter (ml) vial-neb. Inhale by mouth three times a day for shortness of breath. -Benefiber powder 3 grams (gm)/4 gm (prebiotic fiber supplement). -Tube of Aspercreme (pain relief) with 10% trolamine salicylate cream. -In the unlocked drawer below the medication cabinet a bottle of Benefiber powder 3 gm/4 gm. On 2/21/25 at 10:44 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #2's room: -Three small bottles of Nystatin (antifungal) 100000 unit/1gm powder, one with no cap and two sealed with caps. -One larger bottle of Nystatin topical powder. On 2/21/25 at 11:00 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #61's room: -One bottle of guaifenesin (chest congestion)100 mg/5 ml liquid, almost empty. -One bottle chest congestion [NAME] (treat chest congestion)100mg/5 ml liquid. Stored in the unlocked cabinet below the medication cabinet the following medications were observed: -One bottle chest congestion [NAME] 100 mg/5 ml liquid. -Three bottles of Polyethylene Glycol 3350 (treat constipation). On 2/21/25 at 11:35 A.M., the surveyor observed the following medications stored on the top of the medication cabinet in Resident #20's room: -Mirtazapine (antidepressant) 7.5 mg give one tab at bedtime, 15 pills in blister pack (packaging in which a pill is sealed in plastic individually on a cardboard backing). -Pantoprazole (Reduces acid in stomach) 40 mg 1 tab every day, 15 pills in blister pack. On 2/21/25 at 11:36 A.M., the surveyor observed the medication cabinet unlocked in Resident #267's room and observed 23 blister packages of medications and a box of Albuterol Sulfate 2.5 mg/3 ml vial-neb. During an interview on 2/21/25 at 1:31 P.M., the Director of Nurses said all prescription medications in the residents' rooms should be locked in the medication cabinet. If a resident is assessed to self-administer medications, then the medication can be stored in their locked drawer.

Based on record review, observation, and interview, the facility failed to ensure services provided by the facility met professional standards of practice for two Residents (#5 and #14), out of a total sample of 15 residents. Specifically, the facility failed 1.) For Resident #5, to ensure that pressure relieving booties were applied per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2.) For Resident #14, to a.) obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) to document that the air mattress was checked for functioning and setting every shift. Findings include: 1.) Resident #5 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 2/25/22, indicated the Resident requires extensive assist with bed mobility and had impairment of range of motion to his/her lower extremity. Further review of the MDS indicated the Resident was at risk for developing pressure ulcers and was receiving pressure relieving devices in the bed and wheelchair. Review of Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - heel booties on at bedtime. To be removed when out of bed (8/17/21) On 5/31/22 at 9:30 A.M., the surveyor observed Resident #5 in bed. He/she was lying on their back with their feet flat on the mattress with no booties on. On 6/1/22 at 9:52 A.M., the surveyor observed Resident #5 in bed. He/she was lying on their back with their feet flat on the mattress with no booties on. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022, indicated the staff were documenting that the heel booties were in place on 5/31/22 and 6/1/22 on the 7:00 A.M. - 3:00 P.M. shift. During an interview on 6/2/22 at 2:50 P.M., the Director of Nurses (DON) said if a Resident has orders for booties while in bed it would be her expectation that the booties would be on the Resident. The DON said she was unsure why the booties were not on the Resident. During an interview on 6/2/22 at 5:43 P.M., the DON said the nurse on the 11:00 P.M. - 7:00 A.M. shift was supposed to put the booties on the Resident. The DON said the Resident said the staff never put them on him/her. 2.) Resident #14 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/18/22, indicated the Resident was at risk for pressure ulcers and had a pressure relieving device to his/her bed and wheelchair. On 5/31/22 at 10:30 A.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress (a mattress designed to protect against pressure ulcers by allowing air to flow through). The mattress was set at #5. On 6/1/22 at 8:30 A.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress. The mattress was set at #5. On 6/2/22 at 2:42 P.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress. The mattress was set at #5. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Skin: pressure reducing mattress - Notes: air mattress in place: check functioning and setting every shift (4/5/22) Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR), dated May 2022 and June 2022, failed to indicate documented evidence that the air mattress was being checked every shift for functioning and setting. Review of the Nursing Progress Notes, dated 5/1/22 - 6/2/22, failed to indicate any documented evidence that the air mattress was being checked every shift for functioning or setting. Observation of the air mattress indicated a sticker on the air mattress pump machine that indicated that the setting of the air mattress should be set according to the weight of the Resident. Setting #5 indicated a weight of 300-425 pounds. Review of the Resident's weights indicated the Resident's current weight was 177 pounds. During an interview on 6/2/22 at 12:53 P.M., Unit Manager #1 said there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/2/22 at 3:00 P.M., the Director of Nurses said air mattresses are set at a number based on the Resident's weight.

Based on observation, record review, and staff interview, the facility failed to ensure treatment and services for the care of an indwelling catheter (tube inserted into the bladder for urine drainage) were provided in accordance with professional standards and facility policy for one Resident (#32), out of a total sample of 15 residents. Findings include: On 5/31/22 at 10:00 A.M., the surveyor observed Resident #32 sitting up in his/her wheelchair with a Foley catheter bag attached to the side. Review of the facility's policy titled Urinary Catheters, dated 6/2021, indicated, but was not limited to the following: - provide catheter care every shift. Wash with warm soap and water. - change drainage bag monthly (label with date, and time changed) unless otherwise specified by the provider - nursing staff will assess for potential evidence of symptomatic [CONDITION(S)] (urinary tract infection), pain at insertion site, or other changes in urine condition and notify the provider if change is noted - nursing staff will assess catheter for leakage from site of insertion to the bag Resident #32 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 4/14/22, indicated the Resident had an indwelling catheter. Further review of the MDS indicated the Resident required extensive assist with transfers and toileting. Review of the Physician's Orders, dated May 2022, indicated the following: - Foley catheter care per protocol Review of the Treatment Administration Record (TAR), dated May 2022, failed to indicate documented evidence the Foley catheter bag was changed in May 2022 or that the nursing staff were assessing for pain or for symptoms of a [CONDITION(S)] per the facility policy. Further review of the Physician's Orders indicated there were no orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the physician orders failed to have orders for the size and type of catheter and changing of the catheter bag. The Physician's Orders did not indicate to monitor placement of the catheter or to ensure there were no kinks in the tubing or leakage. Review of the Nursing Progress Notes, dated 5/1/22 - 6/1/22, did not provide documented evidence that Foley catheter care was being done per facility policy and physician's orders. During an interview on 6/2/22 at 3:12 P.M., Nurse # 2 said that usually if a Resident has a Foley catheter then the Resident would have orders for the size and type of catheter along with the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations and interviews the facility failed to ensure that staff implemented infection prevention and control practices. Specifically, facility staff failed to change gloves when soiled, appropriately extend the use of personal protective equipment (PPE), and wear the appropriate PPE for high contact care to reduce the risk of potential transmission of COVID-19 within the facility. Findings include: Review of the guidance The Centers for Disease Control and Prevention (CDC) strategies for optimizing the supply of N95 respirators, updated 11/23/20 indicated: -Reuse refers to the practice of using the same N95 respirator by one Health Care Provider (HCP) for multiple encounters but removing it (i.e. doffing) after each encounter. -N95 and other disposable respirators should not be shared by multiple HCP -It is important to perform hand hygiene before and after the previously worn N95 respirator is donned or adjusted 1. On 1/20/21 at 9:50 A.M., the surveyor observed a sign outside of Resident #4's room, indicating that the resident was on airborne precautions. On 1/20/21 at 10:30 AM., the surveyor observed Certified Nursing Assistant (CNA) #1 approach Resident #4's room. CNA #1 doffed (removed) her current face mask/respirator, put it in a paper bag on the precaution cart outside of Resident #4's room, then take a different respirator from a paper lunch bag and don the respirator. CNA #1 then performed hand hygiene, donned a gown and gloves, and entered Resident #4's room. While CNA #1 was in the room with the resident, Nurse #1 was observed to approach the precaution cart outside of the room. Nurse #1 donned and doffed PPE in the following order: donned gown, donned gloves, doffed current respirator and placed it in a paper lunch bag, donned a different respirator from a paper lunch bag (contaminating the gloves that she was wearing), donned goggles and then closed the top drawer of the plastic precaution cart. Nurse #1 then entered the room by turning the door handle and closing the door behind her, still wearing the contaminated gloves. On 1/20/21 at 10:35 A.M., the surveyor observed CNA #1 exit Resident #4's room. CNA #1 stood at the precaution cart and doffed her current respirator, put it in a paper bag, and then picked up another paper bag and donned a different respirator. At this time, the surveyor asked CNA #1 how she knew the respirator in the paper bag was the one she was previously wearing. CNA #1 said the staff labels the paper bags with their names; CNA #1 then flipped over the paper lunch bag to demonstrate and discovered the respirator currently on her face belonged to Nurse #1 who was in the room with the resident. CNA #1 looked through the paper lunch bags and was unable to locate which bag contained her previous worn respirator. During an interview on 1/20/21 at 10:45 A.M., CNA #1 said the staff wears one mask throughout the unit. However, if they have to enter a room of a resident on airborne precautions, then the staff have a designated respirator kept outside the room to wear into the room and then must remove the respirator upon exiting the room. A review of staff education dated 12/31/20 regarding PPE guidance indicated while caring for a resident who was on airborne precautions staff would use a separate N95 respirator for the precaution rooms. 2. On 1/20/21 at 9:55 A.M., the surveyor observed a sign posted at the Cardinal-Maple unit's nurse's station indicating that all staff was to wear N95 respirators, eye protection, and a gown when entering resident rooms. On 1/20/21 at 10:20 A.M., the surveyor observed CNA #1 and CNA #2 enter Resident #5's room. Both CNA #1 and CNA #2 performed hand hygiene, put on gloves, and then repositioned Resident #5, who was in a wheelchair, touching his/her legs and upper body. CNA #1 and CNA #2 did not put on a gown. During an interview on 1/20/21 at 10:10 A.M., CNA #2 said that only some residents needed gowns during care. CNA #2 said for Resident #5 the staff did not have to wear a gown during care. CNA #2 said she was not sure if there was a list of residents to wear gowns with, but that no residents who reside in that particular hall required gowns during care. During an interview on 1/20/21 at 10:22 A.M., CNA #1 said that gowns were to be worn when going in to a room for a resident on precautions. During an interview on 1/20/21 at 1:50 P.M., the Administrator and the Director of Nurses said the facility staff were educated on 12/31/20 to utilize gowns during high contact care for all residents who were not on additional precautions. She said high contact care included transfers, repositioning, ambulating and personal care.

Based on staff observation and staff interview the staff failed to utilize personal protective equipment (PPE) according to the facility's Transmission-based precautions Policy/Protocol, dated 8/20/20, to prevent potential spread of COVID-19 in the facility. Findings include: During interview, the Infection Control Preventionist (ICP)and the Administrative team said that Eye Protection must be worn on all units at all times. They further said that the residents who are quarantined require full PPE (including an N95 mask). On 7/23/20 the facility was directed by the administrative team to implement the following: Gown use only for precaution rooms moving forward Eye protection and surgical mask (N95 for rehab staff) when on neighborhoods (resident units) in resident areas Eye protection, N95, gloves and gown when in precaution rooms(quarantine rooms) gloves will no longer be worn in the hallways Doffing stations will be minimized in the stairwells except boxes for decontaminated masks and wipes for eye protection. Facility policy dated 8/20/20 indicates that residents who are admitted from the hospital will be placed in strict isolation and staff will wear full PPE (gloves, gowns, protective eye wear and N95 respirator). The facility has three units, two units on the first floor which are considered the Long Term Care (LTC) units and the second floor which is the Short Term Rehabilitation (STR) unit. At 8:45 A.M. the surveyor entered the STR unit and observed CNA #1 (certified nursing assistant) who had finished providing care to a resident who was being quarantined. The CNA doffed her isolation gown, placed the laundry into a bag, and proceeded to the laundry area and placed the laundry bag into the washer (the units have washing machines located on the unit) CNA #1 did not have on any eye protection donned. At 9:25 A.M., CNA #1 was observed in the same resident's room (quarantined) with an isolation gown loosely tied around her neck and no eye protection on. The surveyor went to alert the nurse and when the nurse came to make the observation, the CNA had tied the neck ties correctly (tighter), however the back tie remained untied. The nurse indicated to the CNA that she needed to wear eye protection. The CNA stated that she had asked for eye protection but never received it. The Nurse immediately obtained eye protection and gave it to CNA #1. At 10:00 A.M., the surveyor and the ICP were on the LTC unit. The surveyor and the ICP observed two CNAs in a resident's room. One CNA had the proper PPE donned (mask and eye protection as required per the facility policy) and the other CNA with only a mask donned. The ICN immediately corrected the CNA indicating that she needed eye protection. As per the facility policy, all staff needs to have masks and eye protection, at all times, while caring for the residents on the LTC units and full PPE on the STR unit while caring for quarantined residents). At 11:55 A.M., the surveyor exited the conference room and observed the receptionist and a staff member, who was folding washable isolation gowns and conversing with the receptionist. The staff member who was folding the isolation gowns was observed to have her mask around her neck. The surveyor immediately went to alert the ICP. When the surveyor and the ICN approached the reception area, the staff member had donned her mask. The ICP questioned the staff member who now had her mask on and she admitted to the ICP that it had not been in place and apologized for not having it in place. On 8/25/20 at 12:15 P.M,. the Administrator, Assistant Administrator, Director of Nursing and the ICP said that the above observations were infection control breeches in which the staff did not utilize personal protective equipment (PPE) according to the facility's policy/protocol, as required to prevent potential spread of COVID-19 in the facility.

Based on observations, staff interviews, Infection Control Policy review and Centers for Disease Control (CDC) guidelines, the facility failed to ensure that staff consistently follow the appropriate personal protection equipment (PPE) and hand sanitizing guidance, to prevent the potential spread of infection (e.g., COVID-19) for a total census of 50 residents. Specifically, the facility staff were observed wearing full PPE in non-clinical areas after direct care with residents, not consistently disinfecting their hands after close resident contact and wearing the same PPE (gown) into different resident rooms with a COVID-19 negative status. Findings include: The Centers for Disease Control (CDC) guidance, Nursing Home and Long Term Care Facilities 6/25/2020, defines Coronavirus or COVID-19 as an illness caused by [MEDICAL CONDITION] that can spread from person to person with symptoms that can range from mild (or no symptoms) to severe illness. You can become infected by coming into close contact (about 6 feet or two arm lengths) with a person who has [MEDICAL CONDITION]. You can become infected from respiratory droplets when an infected person coughs, sneezes, or talks. You may also be able to get it by touching a surface or object that has [MEDICAL CONDITION] on it and then by touching your mouth, nose, or eyes. Given their congregate nature and resident population served (older adults), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, including [MEDICAL CONDITION]. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (CDC: The CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection (CDC: Infection Control Guidance, July 15 2020). The Department of Public Health (7/6/20), high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of healthcare providers include the following examples: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. Review of the facility's Infection Prevention and Control Preventing Transmission of Infectious Agents (6/2019 page 2 of 13) indicates the following: A. Hand hygiene should be performed immediately after exposure or possible exposure to infectious materials or sources of potentially infectious materials. B. Personal Protective Equipment: Before leaving the resident's room or apartment, remove and discard PPE. 1.) On 7/16/20 at 1:30 P.M., the surveyor observed Nurse #1 wearing a face mask and yellow gown. The surveyor observed the Nurse going in and out of resident rooms responding to call lights without changing her gown. The surveyor interviewed Nurse #1. She said that it was okay to wear the same gown only between the negative resident rooms. (COVID-19 negative residents remain on Droplet precautions and require full PPE. The donning and doffing of new PPE should be done upon entry to the room because it is assumed that residents could be pre-symptomatic or asymptomatic, but potentially infectious with COVID-19. Doffing of potentially contaminated PPE should be done before exiting the resident's room followed by hand sanitizing. (CDC-Coronavirus Disease 2019 Updated Guidance 7/15/2020) 2.) On 7/16/20 at 2:15 P.M., the surveyor interviewed a speech therapist (ST) on the same unit where the previous observation had occurred. The ST said that she also wears the same gown between only the negative rooms. 3.) On 7/16/20 at 3:09 P.M., the surveyor observed a staff member (admission coordinator) appropriately wearing a surgical mask (over nose and mouth) and a long-sleeved white gown, but no eye protection or gloves in a Resident's room. The room had a sign on the door instructing staff to wear full PPE upon entry (mask, gown, eye protection and gloves). The Resident was a new admission (June 2020) and was being quarantined for 14 days. The surveyor observed a hand sanitizer dispenser just outside the room on the wall. The staff member was touching the bedside table and speaking closely (within 6 feet) to a Resident. The surveyor observed the staff member assisting the Resident (touching the Resident's clothing) down the hallway and back to the Resident's room and transferring the Resident to a recliner chair. The staff member again, was touching surfaces in the Resident's room (bedside table and chair). The surveyor observed the staff member exit the room without doffing the potentially contaminated gown and without disinfecting her hands. She walked down the hallway with her gown on and exited the clinical area through double doors and into her office (a non-clinical area). The surveyor interviewed the admission coordinator following the observations. She said that she was giving the Resident a tour of the unit, but could not tell the surveyor what the Resident's precaution status was and therefore, did not know the correct PPE to don/doff upon entry/exit to the Resident's room. She also said that she was told that she could wear a gown into a non-clinical area if she had not provided direct resident care (ambulating/transferring the resident is considered high contact care and therefore, full PPE is required and should be doffed upon exit from the room along with hand sanitizing (according to CDC guidance for all transmission based precautions).

Based on observation, documentation review and interviews, facility staff failed to ensure there was a system by which the maintenance department conducted inspections of all beds in use in the facility for the possibility of entrapment besides the zones for the functioning of the bed rails, including when there was a change in the mattress or bed frame to avoid potential risk of entrapment for 1 resident (#25) out of a total sample of 16 residents. Findings include: Review of the facility policy for bed rails, (updated 6/2019), indicated the following: -the maintenance department or designee will conduct inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment and to make sure bed rails are still installed correctly -when bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bed frames that are compatible. Resident #25 was admitted to the facility in 6/2019 after sustaining a [MEDICAL CONDITION] from a fall at home. Review of the admission Minimum Data Set (MDS) with a reference date of 6/20/19, indicated that Resident #25 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, required extensive assistance from staff for activities of daily living, and was receiving Hospice services. Nursing progress notes dated 6/18/19 indicated that a care plan meeting was held on that day with a Hospice recommendation for a scoop mattress. The scoop mattress was delivered and placed on Resident #25's bed on 6/19/19. During interview with the Maintenance Director on 8/8/19 at 1:30 P.M., the surveyor asked if he had reassessed Resident #25's bed after receiving the new scoop mattress on 6/19/19. He said that he was not aware that Resident #25 had received a new mattress on 6/19/19, and did not conduct an inspection to ensure that they are compatible, or assess for risk of possible entrapment. He said that either the purchasing department, or housekeeping, order mattresses for the building and he is not notified when this is done. Therefore he does not inspect the beds when new mattresses are ordered for Residents. The Maintenance Director explained that in 6/2019, he was provided a special measurement tool, training, and Bed System Measurement Device Test Results Worksheet to document the assessment results, and began assessments for all beds with side rails in 6/2019. A routine maintenance program consisted of daily rounds of 6 resident rooms a day and includes visual inspection of the bed frame, mattress, and side rails and slides his hand between the side rail and mattress to make sure there is not a gap. The Maintenance Director and surveyor toured 2 of 2 units and identified a total of 18 beds with side rails in use. Review of bed assessment documentation indicated that of the 18 beds identified as having bed rails in use, only 5 had been assessed at all. The 5 assessments indicated that inspections for entrapment were conducted only where the bed rails were located (Zones 1, 2, 3 and 4). He said that he does not conduct inspections for risk of entrapment between the mattress and headboard or footboard. During interview with the Assistant Administrator, Maintenance Director, and the Staff Educator on 8/12/19 at 10:04 [NAME]M., the Assistant Administrator confirmed that bed rail assessments began in 6/2019 and consisted of inspection of zones 1, 2, 3, and 4, and did not include inspections for risk of entrapment between the mattress and headboard or footboard. He said that they did not have a system in place to alert the Maintenance Director when new mattresses are obtained so they could be inspected. Following interview with facility administration, it was determined that the remaining beds in use in the facility were also affected.

Based on record review, observation, resident and staff interview, the facility failed to ensure for 3 residents, (#7, #11 and #19) that comprehensive, person-centered care plans were developed that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment, in a total sample of 16 sampled residents. Findings include: 1. Resident #7 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, received anti-psychotic, anti-anxiety, and anti-depressant medication daily, and received Hospice services. Review of comprehensive care plans included the following: Problem: -Medications; reason for taking anti-psychotics include yelling, trying to hit staff members, hallucinations Approaches: -I will receive my medication from the nurse as ordered by the physician -staff will monitor for side effects/adverse effects of medications -I will have behaviors monitored -I am on [MEDICATION NAME], monitor for increased depression -I am on [MEDICATION NAME] for increased agitation and hallucinations Goals: -The nurse and/or caregiver will administer my medication as prescribed and monitor for side effects daily. Problem: - Cognitive Patterns, Mood, and Expressions: hallucinations, remove clothing, fidget in chair, and pray loudly Approaches: -Continue to invite me to programming to help maintain my maximal level of cognitive functioning -Hold my hand, offer me hand massages, verbal reassurance, my animated cat when I become anxious -I find comfort in chanting prayers -Administer psychoactive medications as ordered Goals: -I will maintain usual level of orientation to self, place, day, time, and /or team members daily, I would like to have at a minimum 6-8 hours of sleep throughout the night daily. 2. Resident #11 was admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. Review of most recent quarterly MDS, dated [DATE], indicated that Resident #11 had severe cognitive impairment as evidenced by a BIMS score of 2 out of 15, exhibited physical behaviors toward others, required extensive assistance from staff for activities of daily living, and received anti-psychotic and anti-depressant medication daily. Review of comprehensive care plans included the following: Problem: -medications: [REDACTED] Approaches: -Staff will administer my medication per MD order and monitor me for any adverse side effects and report to provider for options Goals: -The nurse and/or caregiver will administer my medication as prescribed and monitor for side effects daily. Problem: -Cognitive Patterns, Mood, and Expressions: I become anxious Approaches: -Continue with mental health support at MGH (Massachusetts General Hospital) -Find 1:1 interactions reassuring Goals: -I will maintain usual level of orientation to self, place, day, time, and /or team members daily 3. Resident #19 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Review of the most recent annual MDS , dated 6/3/19, indicated that Resident #19 was cognitively intact as evidenced by a BIMS score of 15 out of 15, and had anxiety, and depression. Review of comprehensive care plans included the following: Problem: -Cognitive Patterns, Mood, and Expressions: I become anxious, depressed Approaches: -I enjoy 1:1 conversation with friends, family, and staff members -I will try to convey my feelings with staff and my family in a positive manner -I continue to receive mental health support for medication management. Goals: -I would like to have a reduction in the number of mood changes or outbursts throughout my stay -I will need your assistance to decrease the episodes of negative outbursts and or expressions throughout my stay -I will need your assistance in stepping away from situations that agitated or upset me throughout the month. The facility utilized care plan templates titled, Erickson Holistic Care Plans which were developed for use throughout the Erickson campuses which included independent living, rest home living, and skilled nursing care. The care plan templates were generic and failed to address needs unique to the residents while receiving skilled level of care with measurable outcomes to ascertain if identified approaches were effective. During interview with Unit Manager #2 on 8/09/19 at 9:40 [NAME]M., she said that care plans were not comprehensive; resident centered, and did not include measurable goals. She said that the care plan template utilized by the facility is the same template used throughout the company's campuses and are not well suited for care plan development for the needs of residents in short and long term care, as required.

Based on record review and interview, the facility failed ensure that residents and/or their representatives were fully informed in advance, and given information necessary to make health care decisions including the risks and benefits of [MEDICAL CONDITION] medications prior to their use for 1 resident (#25) from a total sample of 16 residents. Findings include: Resident #25 was admitted to the facility in 6/2019 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), with a reference date of 6/20/19, indicated that Resident #25 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) Score of 6 out of 15, exhibited no behaviors, required extensive assistance from staff for activities of daily living, was administered [MEDICAL CONDITION] medications daily, and had an activated health care proxy. Review of the medical record included the following physician's orders [REDACTED].>-[MEDICATION NAME] HCL ER (anti-depressant) 75 mg (milligrams) once daily, initiated 6/13/19 -[MEDICATION NAME] (anti-depressant) 0.25 mg three times daily, initiated 6/13/19 Review of [MEDICAL CONDITION] consents, signed by the activated health care proxy indicated the following: -[MEDICATION NAME] HCL ER, 75 - 150 mg; signed on 6/18/19 -[MEDICATION NAME] 0.25 - 3.0 mg; signed on 6/18/19 Review of the 6/2019 Medication Administration Record, [REDACTED]. During interview with Unit Manager #2 on 8/9/19 at 12:21 P.M., the surveyor alerted her that [MEDICAL CONDITION] medications were administered prior to obtaining signed informed consent, as required.

Based on record review and interview, the facility staff failed to provide adequate supervision to prevent accidents for 2 residents (#24 and #42), from a total of 16 sampled residents. Findings include: 1. For Resident #24 the facility staff to provide adequate supervision during personal hygiene care as indicated in the plan of care. Review of the medical record indicated Resident 24 was admitted to the facility in 6/2017. Resident #24 medical [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), assessment dated as completed 3/15/19 indicated the resident required extensive assistance. Resident involved in activity staff provided weight bearing support. The MDS indicated Resident #24 required one person physical assist during personal hygiene care. Review of the facility incident narrative, dated 5/31/19 at 8:55 P.M., indicated the resident was found on the floor in his/her bathroom by a Care Associate (CA). The incident narrative indicated that the CA immediately called for the nurse. The incident narrative indicated the nurse assessed the resident and assessed for right shoulder pain. Furthermore, the incident narrative indicated the resident denied striking his/her head or loss of consciousness at the time. Resident #24's health care proxy (HCP) and the physician were notified. The resident and the HCP refused for the resident to be transferred to the hospital for an evaluation. A physician order [REDACTED]. Review of the internal investigation narrative revealed prior to the fall, the resident was assessed for falls. The internal investigation indicated at the time of the fall, Resident #24 was assisted to his/her bathroom to brush his/her teeth. The narrative indicated the CA left the resident alone to obtain supplies to provide afternoon personal hygiene care to the resident. Upon returning, the resident had already fallen in the bathroom. The internal investigation indicated the resident said after he/she was done brushing his/her teeth, he/she proceeded to return to bed, noticed a plastic bag on the floor, attempted to pick it up, leaned forward and fell over hitting his/her right shoulder. Review of a statement from the CA that had provided care to the resident indicated that the resident was left unattended during personal hygiene, which he/she required to have one person physical assist. Review of the Interim physician's orders [REDACTED]. The portable X-ray was obtained on 6/1/19 and revealed that the resident sustained [REDACTED]. On 6/1/19 at 10:40 [NAME]M., the Interim physician's orders [REDACTED]. On 6/1/19 at 11:40 [NAME]M., the Interim physician's orders [REDACTED]. On 8/9/19, review of the Resident's care plan dated as initiated 3/18/19 indicated that Resident #24 required the following support: One person physical assist during personal hygiene care. The care plan included the following approaches: Ensure that all needed articles were in reach and available for the resident to use; check to making sure he/she had what needed before leaving the room; and he/she got tired easily some days and repeated motions tired him/her out easily therefore he/she required assistance. On 8/9/18 at 3:15 P.M., The surveyor interviewed the Director of Nurses (DON) with regards to Resident #24's unwitnessed fall. The DON said she reviewed the incident report as well and found that the resident did in fact fall in his/her bathroom and sustained a fracture. On 8/13/19 at 9:39 [NAME]M. the Surveyor interviewed Unit Manager #2 with regards to Resident #24 unwitnessed falls. She confirmed that resident was left in the bathroom unattended and sustained a fall with a fracture. The Care Associate involved was not available for an interview throughout the survey duration. 2. For Resident #42 the facility staff failed to provide adequate supervision to prevent fall accident. Review of the clinical record indicated Resident # 42 was admitted to the facility in 7/2018. Resident #42 medical [DIAGNOSES REDACTED]. On 08/08/19 at 10:37 [NAME]M., during survey observation the surveyor noticed a flag Interim physician's orders [REDACTED]. Upon reviewing, the following orders were noted: 1) 8/7/19 X-ray on right hand status [REDACTED]. 2) telephone order: clarification of X-ray on left hand s/p fall to r/o fracture and scheduled provider visit in the morning to assess the Resident and review X-ray results. On 8/8/19 the provider reviewed the X-ray, assessed the resident and gave an order to discontinue skilled therapy services. Review of a nurse's note, dated 8/4/19 at 06:17 P.M., indicated that Resident #42 was found lying/sitting on lounge room floor, denied hitting his/her head. The nurse's note indicated resident said he/she wanted the box of tissues that was on the shelf. The nurse's noted indicated the Resident vital signs were within normal limit. Resident range of motion was within normal limit, no pain or discomfort assessed at the time of the fall or during the remainder of the shift. The nurse's note further indicated the Resident's neurological signs were within normal limit through the remainder of the shift, the health care proxy and the physician were notified. Review of the incident narrative dated 8/4/19 at 2:30 P.M., indicated Resident was found on the floor in the common area lying on his/her back. The incident narrative indicated that the Resident was immediately assessed by the nurse and had no pain or injury. The incident report indicated the Resident said he/she was attempting to obtain a tissue, slid off the wheelchair landing on his/her buttocks. The Resident health care proxy and physician were notified. The incident report indicated on 8/7/19, the Resident denied having pain however a small bruise was noted on his left hand. The incident report indicated the physician was notified and an order was obtained for an X-ray to the affected area. Review of the internal investigation narrative indicated Resident #42 required extensive assist for transfers and ambulation. The investigation narrative indicated Resident #42 utilized a wheelchair for mobility, required mechanical lift during transfer occasionally. Review of the annual Minimum Data Set (MDS) assessment dated as completed 7/26/19, indicated Resident #42 was severely cognitively impaired. The MDS indicated Resident required extensive assistance for ambulation and transfer. The MDS indicated Resident required 2 plus person physical assist for moving from seated to standing position, and surface to surface transfer. The MDS indicated the Resident required staff assistance from seated to standing position as the Resident is not steady, only able to stabilize with staff assistance. On 8/8/19, review of a nurse's note dated 8/7/19 at 8:55 P.M., indicated Resident X-rays reveals 6 millimeters shoulder dissociation and hand fracture. Provider notified and gave new instructions to call medical center in [NAME]M. for provider visit to see resident and review X-ray results. The resident was monitored for pain, no signs and symptoms of pain, denied pain. Resident currently back in bed and sleeping comfortably. The health care proxy (HCP) was notified and agreed with the plan of care. On 08/08/19 02:09 P.M. Resident #42 was observed sitting on his/her wheelchair with a left hand that was swollen, dark blue color in appearance and was rested on a pillow; the right arm was observed to have reddish color bruises. On 8/9/18 at 3:15 P.M., The surveyor interviewed the Director of Nurses (DON) with regards to Resident #42 unwitnessed fall. The DON said she would double check on that incident report. Later that afternoon the DON confirmed that the resident was in the lounge room unattended when sustained the fall on 8/4/19. On 08/13/19 10:43 [NAME]M., during an interview with care associate #2, she said Resident #42 required 2 assist at all times even when ambulating with the walker. The care associate said resident cognitive level varied at times. She said she had never witnessed the resident attempting to self-ambulate self when providing care. On 8/13/19 at 10:15 [NAME]M. the surveyor interviewed Unit Manager #2 with regards to Resident #42 unwitnessed fall. She confirmed that resident was found on the floor in the lounge room and sustained a fall with a fracture.

Based on record review and interview, the facility failed to ensure that PRN (as needed) orders for [MEDICAL CONDITION] medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it is appropriate to extend beyond 14 days for 1 resident (#7), out of a total sample of 16 residents. Findings include: Resident #7 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 5/7/19, indicated that Resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and received anti-psychotic, anti-anxiety, and anti-depressant medication daily. Review of the medical record indicated a physician's orders [REDACTED]. The order was open ended with no end date. Further review of the medical record failed to indicate documentation that Resident #7's PRN order for [MEDICATION NAME] was re-evaluated by the attending physician or psychiatric consultant to determine that it was appropriate to extend beyond 14 days as required. During interview on 8/9/19 at 12:21 P.M., Unit Manager #2 said that Resident #7's PRN order for [MEDICATION NAME] should have been re-evaluated after 14 days for it's continued use, as required.

Based on record review and interview, the facility staff failed to ensure that the Resident Assessment accurately reflected the resident's status for one resident (#42), from a total of 16 sampled residents. Findings include: Resident # 42 was admitted to the facility in 7/2018 with multiple [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated as completed 7/26/19, indicated that Resident #42 was severely cognitively impaired. The MDS also indicated that Resident #42 vision was adequate with corrective lenses. Review of the Resident care plan, dated 7/05/19, addressing Hearing, Speech and Vision documented that the Resident had no vision problem. The care plan included the following goal: -I will continue to be independent with my vision -I will alert staff of any changes in my vision On 08/13/19 at 11:02 [NAME]M., during an interview with Unit Manager #1, she said that the annual MDS was inaccurately coded during the assessment of the Resident vision ability.

Based on review of Minimum Data Set (MDS) for 1 resident (#1), as part of the Resident Assessment task, and staff interview, the facility failed to electronically transmit to the Quality Improvement Evaluation System (QIES), Assessment Submission and Processing (ASAP) System, a completed MDS within 14 days of discharge from the facility. Findings include: Review of MDS assessments for Resident #1 indicated an assessment was completed for a Discharge-Return Not Anticipated on 8/6/19 for a discharge date of [DATE]. During interview with the MDS Nurse on 8/13/19 at 8:41 [NAME]M., she said that the discharge assessment had not been completed and transmitted within 14 days as required.

Based on observation and interview, the facility failed to ensure that pharmaceutical services provided follow procedures to assure emergency kits used in the facility are replaced after opening. Findings include: Review of the Facility Policies and procedures included: When a kit is opened, the nurse responsible informs the pharmacy which kit number has been opened, which med has been removed and for whom the med was used. The pharmacy will exchange a sealed, updated start/Emergency Drug Kit within 48 hours. On 08/13/19 at 09:35 [NAME]M., the surveyor conducted a review of the medication storage room on the Monarch/Tulip Unit with Nurse #1. Upon reviewing the medication storage room, it was observed that the intravenous emergency Kit #R-237 was opened. The Omnicare intravenous emergency kit (E-Kit) Report sheet was blank; there was no indication of which supply was removed by nursing staff from the kit and when the kit was opened. Nurse #1 said she was not aware that the intravenous emergency kit was opened. Nurse #1 was unable to verify what was removed from the kit. On 08/13/19 at 09:45 [NAME]M., during an interview with nurse #1 she said the nursing staff that opened the kit should have completed the Omnicare Intravenous Emergency Kit (E-Kit) Report, indicating what was removed and who the supply removed was used for and then fax the form to the pharmacy for a replacement.

Based on record review and staff interview, facility staff failed to ensure that for 2 residents (#7 and #11), of a total sample of 16 residents, that care and treatment was provided in accordance with accepted Professional Standards of Practice. Findings include: 1. For Resident #7, facility staff failed to ensure that prn (as needed) [MEDICAL CONDITION] medication was not administered at a dose greater than the informed signed consent obtained from the resident's health care proxy. Resident #7 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 5/7/19, indicated that resident #7 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and received anti-psychotic, anti-anxiety, and anti-depressant medication daily. Review of the medical record indicated a physician's orders [REDACTED]. The consent for [MEDICATION NAME], signed by Resident #7's activated health care proxy on 5/15/19, indicated a daily dose range of 0 - 1mg. Review of Medication Administration Records (MAR) for 5/2019 through 8/2019 indicated that [MEDICATION NAME] was administered in daily doses greater than 1 mg on the following occasions: -5/22 -5/25 -5/30 -6/4 -6/9 -6/14 -6/19 -6/22 During interview with Unit Manger #2 on 8/9/19 at 12:21 P.M., she said that Resident #7 should not have been administered [MEDICATION NAME] in a dose greater than indicated on the consent form signed by the health care proxy. 2. For Resident #11, facility staff failed to ensure that a physician's orders [REDACTED]. Resident #11 was admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. Review of most recent quarterly MDS with a reference date of 5/17/19, indicated that Resident #11 had severe cognitive impairment as evidenced by a BIMS score of 2 out of 15, exhibited physical behaviors toward others, required extensive assistance from staff for activities of daily living, and received antipsychotic and antidepressant medication daily. Further review of the medical record failed to indicate a physician's orders [REDACTED]. A care plan for cognitive patterns, mood, and expressions (initiated 5/16/19), included the following approach, continue with mental health support at Massachusetts General Hospital. The care plan failed to include elements of a psychiatric treatment plan, or identify targeted psychiatric symptoms or behaviors, and had no measurable goals. During interview with Unit Manager #2 on 8/9/19 at 12:23 P.M., she said that Resident #11 is seen by a psychiatrist at Massachusetts General Hospital. However, she did not know how long the Resident had been seeing this clinician, or how frequently. She said that the resident's family accompanied him/her to appointments, there is no collaboration between the psychiatrist and the facility, and that they had never received any information from the psychiatrist's office regarding treatment plans or any medication recommendations. The Unit Manager reviewed the medical record and was unable to find any documentation from the community psychiatrist, and said that information should be shared with the facility. During interview on 8/13/19 at approximately 3:00 P.M., the facility social worker reviewed the Resident's record and was unable to find any documentation from the psychiatric clinician. At approximately 3:35 P.M., the social worker provided the surveyor with a treatment note that was faxed from the psychiatrist's office (date/time stamped 8/13/19 at 3:32 P.M. The note indicated that Resident #11 was last seen by the psychiatrist in Boston on 7/2/19. The focus of the visit was discussion with the Resident's family about an increase in the Resident's somnolence, and consideration of medication adjustments. The psychiatrist recommended a titration in [MEDICATION NAME] be considered.