Every finding on record at Maplewood Center

Based on interview and records reviewed, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for 16 days for the period of 10/1/25 to 12/31/25. Findings include:1. Review of the PBJ Staffing Data Report, dated Quarter 1: 2026 (October 1 - December 31), indicated the following:-One Star Staffing Rating Triggered = Star Staffing Rating Equals 1.-Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low.-No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours. Review of the as worked nursing schedule provided by the facility failed to indicate that a Registered Nurse worked for eight consecutive hours in the facility on the following days:-10/04 -10/05 -10/11 -10/12 -10/18 -10/19 -11/02 -11/08 -11/09 -11/15 -11/16 -11/22 -11/23 -11/29-11/30-12/27 The facility failed to provide evidence through timecards or payroll information that an RN was onsite for eight consecutive hours on the dates noted on the PBJ Staffing Data Report. Further review of the as worked nursing schedules from January 1, 2026, through March 31, 2026, continued to indicate the facility failed to ensure an RN was onsite for eight consecutive hours on the following days: -1/4/26 -1/11/26 -1/18/26 -1/25/26 -1/31/26 -2/8/26 -2/14/26 -2/15/26 -2/22/26 -2/28/26 -3/1/26 -3/14/26 -3/15/26 -3/21/26 -3/22/26 -3/28/26 -3/29/26 During an interview on 4/23/26 at 9:30 A.M., the Administrator said the facility has been working to get RN coverage 7 days a week, but it has been challenging. The Administrator said there should be an RN working at least eight hours every day.

Based on observation and interview, the facility failed to properly follow food storage and infection control practices in the kitchen to prevent the risk of foodborne illness and contamination in accordance with professional standards for food service safety. Specifically, the facility failed to: A. properly date, label and prevent personal food from staff members from being stored with resident food in the kitchen to prevent the risk of foodborne illness and B. ensure non-kitchen staff members were not behind the tray line without performing proper infection control protocols to prevent contamination of ready-to-eat food.Findings include:Review of the facility policy titled Food Storage, undated, indicated the following:- Plastic containers with tight fitting covers must be used for storing flour and sugar. All containers must be legibly and accurately labeled.- Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.A. During the initial kitchen walkthrough on 4/21/26 at 6:50 A.M., the surveyor observed the following:In the Walk-in Refrigerator:- A container labeled egg salad with an expiration date of 4/20.- Containers of open beef broth concentrate with the following dates written on each one: 12/23, 12/23, 1/27, 2/26 and 3/18.- Two containers appearing to have red sauce that were unlabeled and undated- Eight individual containers appearing to be pudding that were labeled with P, no dates were present.- A Styrofoam container stored with Resident food that was plastic wrapped and labeled with a dietary aide's name.- Three hotel pans of pre-poured juice and milk that were not labeled or dated.In the milk refrigerator, a bowl of a beige product appearing to be pudding that was not covered, not labeled and not dated.In the dry storage room:- An open package of Raspberry gelatin mix with powder residue surrounding the package. There was no label or date.- Two large white bins appearing to be storing either flour or sugar that had no labels or date.During the follow-up visit to the kitchen on 4/22/26 at 11:42 A.M., the surveyor observed the following:In the dry storage room:- An open package of Raspberry gelatin mix with powder residue surrounding the package. There was no label or date.During an interview on 4/23/26 at 1:23 P.M., the Food Service Director (FSD) said when any food product is opened or prepared and stored it needs to be labeled and dated. The FSD continued to say all food should be used within three days of being prepared or opened. The FSD then said staff should not be storing personal food items in refrigerators containing resident food.B. During the follow-up visit to the kitchen on 4/22/26 at 11:42 A.M., the surveyor observed the following while watching the lunch tray line:- At 11:55 A.M., a staff member who does not work in the kitchen entered the kitchen without donning a hairnet or performing hand hygiene. The employee walked to the ice machine which was behind the tray line area and scooped ice into a cup, the employee then proceeded to the juice machine to fill up a cup.- At 12:08 P.M., a maintenance staff member entered the kitchen without donning a hairnet or washing his hands. The maintenance staff member proceeded to go directly behind the tray line where the FSD was previously preparing. The maintenance staff member then grabbed a box of tinfoil, laid the tinfoil out on a previously used cutting board, grabbed a knife that was previously used and cut a piece of tinfoil with tray line food in the immediate area.During an interview on 4/22/26 at 12:15 P.M. and on 4/23/26 at 1:23 P.M., the FSD said staff members should not be entering the kitchen without putting on a hair net or washing their hands and they should not be going behind the tray line while meal service is happening.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#64) out of a total sample of 19 Residents. Specifically, the facility failed to ensure respiratory equipment was maintained in a sanitary condition as evidenced by the concentrator used to administer continuous oxygen had filters covered with a thick layer of white dust. Findings include:Review of the facility policy titled Oxygen Administration, dated and revised October 2010, indicated the following:- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Resident #64 was admitted to the facility in December 2025 with diagnoses including pneumonia, acute and chronic respiratory failure and chronic obstructive pulmonary disease. Review of Resident #64's most recent Minimum Data Set Assessment (MD) dated 3/23/26 indicated that the Resident had a Brief Interview for Mental Status score of 9 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires oxygen therapy and does not have behaviors of rejecting care. The surveyor made the following observations:- On 4/21/26 at 8:10 A.M., the oxygen concentrator machine was off and next to Resident #64's bed. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/22/26 at 12:59 P.M., Resident #64 was sitting in his/her bed receiving oxygen via nasal cannula from the oxygen concentrator machine. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/23/26 at 7:29 A.M., the oxygen concentrator machine was off and next to Resident #64's bed. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/23/26 at 11:14 A.M., Resident #64 was sitting in his/her bed receiving oxygen via nasal cannula from the oxygen concentrator machine. The filter on the back on the concentrator was completely covered in a thick layer of white dust.Review of Resident #64's physician's orders dated 12/22/25 indicated the following:- Oxygen dependent 2L NC (2 liters nasal cannula) every shift for COPD, oxygen at 2 L/min (liters per minute) via NC.- Clean oxygen filters: clean oxygen concentrator filters ever Wednesday on the night (11-7) one time a day every Wed.Review of Resident #64's altered repository function care plan dated and revised 1/3/26 indicated the following intervention: Administer medication per MD (medical doctor) order.During an interview on 4/23/26 at 11:25 A.M., Nurse #1 said all physician's orders should be followed and all oxygen equipment including filters should be cleaned every week by the night shift. Nurse #1 and the surveyor proceeded to look at the oxygen filter and Nurse #1 said it was dirty and covered in dust and needs to be cleaned.During an interview on 4/23/26 at 12:14 P.M., the [NAME] President of Clinical Operations said all physician's orders should be followed as written and all oxygen filters should be cleaned regularly to ensure residents are breathing in clean air. The surveyor showed the [NAME] President of Clinical Operations a photo of Resident #64's oxygen filter and she said it was dirty and needed to be cleaned.

Based on observations, record review and interview, the facility failed to obtain a urine sample for laboratory services as ordered by the physician for one Resident (#2) out of a total sample of 19 Residents. Specifically, the facility failed to ensure that a urine sample was obtained to send to laboratory services, as ordered by the physician, to assess for a potential urinary tract infection.Findings include:Resident #2 was admitted to the facility in November 2023 with diagnoses including end stage renal disease and vascular dementia. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for toileting hygiene, requires partial/moderate assistance with toilet transfers and has not exhibited behavior of rejecting care. Review of Resident #2's physician's order dated 4/2/26 indicated the following: Obtain urine to test for UTI (urinary tract infection) with sensitivity. D/C (discontinue) when obtained, every shift.Review of Resident #2's nursing progress note written on 4/2/26 at 10:37 P.M., indicated the following: patient present increase hallucination, assist to toilet, he/she verbalized burning during voiding, order by np (nurse practitioner) to obtain urine.Review of Resident #2's progress note written by the Registered Dietitian on 4/3/26 at 1:33 P.M., indicated the following: Per nursing, Resident #2 with hallucinations, urine to be obtained.Review of Resident #2's Interdisciplinary Team Progress note written on 4/7/26 on 3:59 P.M., indicated the following: Resident #2 was discussed in Risk Meeting due to question of hallucinations. MD (medical doctor) has ordered a UA (urine analysis) to rule out UTI.Review of a binder titled Laboratory Requisition Book at the nursing station on Resident #2's unit failed to indicate any records requesting a urine analysis for Resident #2.During an observation on 4/22/26 at 8:17 A.M., a Certified Nursing Assistant (CNA) assisted Resident #2 to use the bathroom. The CNA and Resident left the bathroom; the CNA did not have a urine sample upon leaving the Resident's room.During an interview on 4/22/26 at 7:53 A.M., Resident #2 told the surveyor that no one has told him/her that a urine sample needed to be obtained, and he/she said that he/she does not remember one ever being collected.During a telephone interview on 4/22/26 at 10:06 A.M., Resident #2's activated Healthcare Proxy said she was never informed of Resident #2 potentially having increased hallucinations or burning while urinating and that the facility never told her that a urine sample was ordered to be obtained.During an interview on 4/22/26 at 10:27 A.M., Certified Nursing Assistant (CNA) #4 said she remembers that within the past two weeks someone told her that Resident #2 needed a urine sample collected. CNA #4 said she did not obtain one from Resident #2 and is unsure if anyone else has.During an interview on 4/22/26 at 10:33 A.M., Nurse #1 said she heard Resident #2 may have had hallucinations after dialysis and wanted to rule out a urinary tract infection but is not sure if the urine sample was ever obtained. Nurse #1 said laboratory services come to the building twice a week to pick up samples.During an interview on 4/22/26 at 10:43 A.M., CNA #2 said no one has ever told her that a urine sample needed to be obtained for Resident #2.During an observation on 4/22/26 at 10:55 A.M., a clean, unused urine hat (a medical device designed to fit on the toilet rim to collect urine) was observed on top of the tank of Resident #2's toilet. During a telephone interview on 4/22/26 at 11:06 A.M., Nurse Practitioner (NP) #1 said she is in the facility two times per week, and she was not sure if a urine sample was ever obtained for Resident #2. NP #1 then said she had no recollection that Resident #2 needed a urine sample. NP #1 said her expectations are if staff could not obtain a urine sample via a urine hat within 72 hours that she would be notified so she could determine an alternative plan.During a telephone interview on 4/22/26 at 11:19 A.M., Physician #1 said if the facility was unable to collect a urine sample within 48 hours, then he should be notified. Physician #1 said he was never notified and he should have been since the urine sample was not obtained since the order was entered on 4/2/26.Review of Resident #2's April 2026 Medication Administration Report indicated that nursing staff signed off every day acknowledging the following order: Obtain urine to test for UTI (urinary tract infection) with sensitivity. D/C (discontinue) when obtained, every shift.During an interview on 4/23/26 at 12:14 P.M., the [NAME] President of Clinical Operations (VPCO) said all physician's orders should be followed as written. The VPCO then said if the facility is unable to obtain a urine sample, then the CNAs and nurses should tell someone so the NP or physician could be notified. The VPCO then said Resident #2's urine sample should have been obtained within a few days of the 4/2/26 order.

Based on record review, interview and observation, the facility failed to implement a physician's order for repositioning one Resident (#8) out of 19 sampled residents. Specifically, nursing staff failed to offer to reposition Resident #8 every two hours for the management of moisture associated skin damage located on the buttocks. Findings include: Resident #8 was admitted to the facility in September 2024, and has active diagnoses of hemiparesis, diabetes, dementia and coronary artery disease.Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) exam of 15 out of 15, signifying intact cognition. In addition, Resident #8 had an impairment on one side, and he/she was dependent on staff for rolling from lying on the back to the right and left side and then return to lying on his/her back in bed. The MDS indicated Resident #8 was at-risk for the development of pressure ulcers and rejected care one to three days a week.Review of Resident #8's active care plan for skin care indicated he/she had moisture associate skin damage (MASD) located on the buttocks. Interventions included, but were not limited to, repositioning the Resident. Review of Resident #8's active physician order dated 7/7/25 indicated Reposition every 2 hours and as needed every shift. Review of Resident #8's Treatment Administration Record (TAR) dated April 2026 indicated staff repositioned the Resident on 4/21/26 and 4/22/26 on the day, evening and night shifts.Review of the Wound assessment dated [DATE] indicated the Resident had moisture associate skin damage located on the coccyx. The assessment indicated Resident #8's wound was improving.Review of Resident #8's active physician order dated 4/21/26 indicated MASD coccyx: apply triad barrier cream with every peri care opportunity every day and as needed. Turn, monitor for any changes. Review of Resident #8's TAR dated 4/21/26 and 4/22/26 indicated staff provided these treatments.On 4/21/26 at 9:39 A.M., Resident #8 said that nursing staff do not reposition him/her and that he/she believes this resulted in the development of skin damage located on his/her buttocks. The surveyor observed that the Resident was lying supine in bed at this time. Resident #8 said he does not refuse to be repositioned.On the following dates and times, the surveyor(s) observed Resident #8 lying supine in bed:4/21/29 at 9:39 A.M. The Resident said no one repositions him/her.4/21/26 at 12:05 P.M. The Resident said no one had offered to reposition him/her.4/21/26 at 2:04 P.M. The Resident said no one had offered to reposition him/her.4/21/26 at 3:44 P.M. The Resident said no one had offered to reposition him/her.4/22/26 at 7:21 A.M. The Resident said no one had offered to reposition him/her last night or this morning.4/22/26 at 9:12 A.M. The Resident said no one had offered to reposition him/her.4/22/26 at 2:43 P.M. The Resident said that at about noon a staff member rolled him/her from the back to side and then to his/her back again to examine his/her toes.4/22/26 at 3:52 P.M. The Resident said no staff had been in his/her room since about noon. The Resident said the assigned Certified Nurse Aide (CNA) for the 3:00 P.M. to 11:00 P.M. shift had not been in his/her room.During an observation on 4/22/26 from 3:52 P.M. to 4:29 P.M., two nursing staff members entered Resident #8's room and exited but did not offer to reposition the Resident. On 4/23/26 at 8:01 A.M., Nurse #1 said she expects nursing staff to follow Resident #8's physician orders, including repositioning him/her every two hours. Nurse #1 said that sometimes Resident #8 refused to be repositioned. Nurse #1 said that CNAs should inform the nurse of any refusals and that this would be documented in the progress notes.During an observation and interview with Resident #8 on 4/23/26 at 9:35 A.M., he/she said no one had offered to reposition him/her today. Resident #8 was lying supine in bed. Resident #8 asked the surveyor if it was his/her responsibility to request to be repositioned.On 4/23/26 at 9:42 A.M., CNA #1 said she was regularly assigned to care for Resident #8. CNA #1 said nursing staff are required to offer to reposition Resident #8 every two hours, and as needed. CNA #1 said the Resident sometimes refused care, including repositioning, but that when this occurred, she informed the nurse. CNA #1 said it is the expectation that when a resident refuses care the aide is to report this to the nurse. Review of Resident #8's progress notes and TAR for April 2026 indicated there was no reference to the Resident refusing to be repositioned.

Based on observation, record review and interview, the facility failed to ensure services consistent with professional standards were provided for one Resident (#2) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 19 residents. Specifically, the facility failed to keep an updated communication book for dialysis care.Findings include: Review of the facility policy titled Dialysis Patients, dated and revised April 2017, indicated the following:- Patients who go to hemodialysis will be managed as follows: A dialysis communication form will be sent with the patient in case of documentation with the facility and the dialysis center. Resident #2 was admitted to the facility in November 2023 with diagnoses including end stage renal disease and vascular dementia. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident receives dialysis treatment and has not exhibited behavior of rejecting care. During an interview on 4/21/26 at 2:06 P.M. Resident #2 said he/she does not remember taking a book to dialysis with him/her recently. During observations on 4/21/26 and 4/22/26, the surveyor was unable to locate a dialysis communication book for Resident #2 at the unit nursing station or in the Resident's room with the Resident's permission. During an observation on 4/22/26 at 10:20 A.M., Resident #2 was getting ready to go to hemodialysis with help from Certified Nursing Assistants (CNAs). The CNAs packed a bag for Resident #2; the surveyor did not see a dialysis book get packed. Review of Resident #2's physician's order dated 7/26/25 indicated the following:- Complete NSG:Dialysis PRE/POST ASSESSMENT Dialysis treatment 3 times/week M/W/F (Monday/Wednesday/Friday) unless otherwise adjusted by hemodialysis center. Pickup around 10am vitals and weight to be obtained prior to leaving and to go with dialysis book. Review of Resident #2's care plan with a focus of needing hemodialysis three times weekly related to renal failure indicated the following intervention dated 7/5/24: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis 3 times/week. During a follow-up observation on 4/23/26 at 11:20 A.M., the surveyor observed a Dialysis Communication Book for Resident #2 at the unit's nursing station. Review of the Dialysis Communication Book only indicated a communication from his/her 4/22/26 dialysis visit. The remainder of the sheets were blank. Review of Resident #2's physical medical chart at the nursing station did not have any dialysis communication records from 2026. During an interview on 4/23/26 at 11:32 A.M., Nurse #1 said Resident #2 goes to dialysis treatment three times each week and he/she should be taking a dialysis book with him/her. Nurse #1 said when the Resident returns from dialysis the communication sheets should be reviewed and then get filed in the Resident's medical chart. Nurse #1 and the surveyor reviewed the Resident's physical medical chart and could not find any dialysis communication sheets for 2026. During an interview on 4/23/26 at 11:45 A.M., the Registered Dietitian (RD) said Resident #2's dialysis book has been missing, and she was not sure how long. The RD said as of yesterday a brand-new dialysis book was made for Resident #2. The RD said she is not sure how the facility has been communicating with the dialysis center. During an interview on 4/23/26 at 12:01 P.M., CNA's #2, #3 and #4 told the surveyor they were not sure how long Resident #2's book was missing and no one told them that it was missing. During a follow up interview on 4/23/26 at 12:07 P.M., Nurse #1 told the surveyor she was not aware Resident #2's dialysis book was missing or for how long it was missing . During an interview on 4/23/26 at 12:44 P.M., Nurse #2 said he was the scheduled nurse for Resident #2 on 4/20/26, which was one of the Resident's dialysis days. Nurse #2 said the CNAs will get the Resident ready before he/she goes to dialysis. Nurse #2 said he had no knowledge that Resident #2's dialysis book was missing or for how long it had been missing. During an interview on 4/23/26 at 1:14 A.M., the [NAME] President of Clinical Operations (VPCO) said she is not in the building regularly. The VPCO said she would expect regular communication between the facility and the dialysis center. The VPCO said she is not sure how long the book has been missing and then said if a dialysis communication was missing then she would expect staff to tell someone. The VPCO then said she made a new dialysis book for Resident #2 last night because she heard it was missing. The VPCO then told the surveyor she would attempt to locate any dialysis communication records for 2026. During a follow up interview on 4/23/26 at 2:29 P.M., the VPCO said she was unable to find any dialysis communication record sheets for 2026. The VPCO said she contacted Resident #2's regular driver to the dialysis clinic who did not report finding a book. The VPCO then said they cleaned Resident #2's bedroom and did not find a dialysis communication book.

Based on observations, record review and interview, the facility failed to accurately document in the electronic medical record for one Resident (#64), out of a total sample of 19 residents. Specifically, the facility failed to ensure staff members accurately documented that oxygen filters were cleaned when they were not.Findings include:Resident #64 was admitted to the facility in December 2025 with diagnoses including pneumonia, acute and chronic respiratory failure and chronic obstructive pulmonary disease. Review of Resident #64's most recent Minimum Data Set Assessment (MD) dated 3/23/26 indicated that the Resident had a Brief Interview for Mental Status score of 9 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires oxygen therapy and does not have behaviors of rejecting care. The surveyor made the following observations:- On 4/21/26 at 8:10 A.M., the oxygen concentrator machine was off and next to Resident #64's bed. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/22/26 at 12:59 P.M., Resident #64 was sitting in his/her bed receiving oxygen via nasal cannula from the oxygen concentrator machine. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/23/26 at 7:29 A.M., the oxygen concentrator machine was off and next to Resident #64's bed. The filter on the back on the concentrator was completely covered in a thick layer of white dust.- On 4/23/26 at 11:14 A.M., Resident #64 was sitting in his/her bed receiving oxygen via nasal cannula from the oxygen concentrator machine. The filter on the back on the concentrator was completely covered in a thick layer of white dust.Review of Resident #64's physician's orders dated 12/22/25 indicated the following:- Oxygen dependent 2L NC (2 liters nasal cannula) every shift for COPD, oxygen at 2 L/min (liters per minute) via NC.- Clean oxygen filters: clean oxygen concentrator filters ever Wednesday on the night (11-7) one time a day every Wed.Review of Resident #64's Treatment Administration Report indicated that staff signed off on the following order on 4/22/26 at 6:00 A.M.:- Clean oxygen filters: clean oxygen concentrator filters every Wednesday on the night (11-7) one time a day every Wed.Resident #64's oxygen filter was covered in a thick layer of white dust before and after the above order was documented indicating that the order was documented inaccurately.During an interview on 4/23/26 at 11:25 A.M., Nurse #1 said all physician's orders should be followed and all oxygen equipment including filters should be cleaned every week by the night shift. Nurse #1 and the surveyor proceeded to look at the oxygen filter and Nurse #1 said it was dirty and covered in dust and needs to be cleaned. Nurse #1 said staff should not be documenting that they cleaned the filter when they did not. Nurse #1 then said Resident #64's oxygen filter was scheduled to be cleaned last night. During an interview on 4/23/26 at 12:14 P.M., the [NAME] President of Clinical Operations said staff should not be documenting physician's orders as being completed when they were not.

4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. Resident #69 was admitted to the facility in November 2024 with diagnoses that include but not limited to paralytic gait, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, and Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS) assessment, dated 5/16/25 indicated Resident #69 scored a 4 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment, requires partial/moderate assistance with self-care activities including bathing, toileting and dressing. Further, review of the MDS indicated Resident #69 was at risk for developing pressure ulcers and had 1 stage 4 pressure ulcer (Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle). Review of Resident #69's MDSs dated 11/17/24 indicated 1 unstageable suspected deep tissue injury in evolution, and the MDS dated [DATE] indicated Resident #69 had 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. On 6/3/25 at 12:17 P.M., Resident#69 was observed in the main dining room with a slipper sock on his/her left foot. On 6/4/25 at 8:34 A.M., Resident #69 was observed in the dining room in a wheelchair with his/her legs resting on the floor. He/she was wearing a red slipper sock on his/her left foot with a white dressing observed just above the top of the red slipper sock. Review of Resident #69's physician's orders indicated the following: -wound consult for left heel and right shin, dated 3/10/25. Review of the care plan with the focus Resident was admitted with a pressure (sic) to his/her left heel dated initiated 11/23/24, revision on 6/3/25. Interventions/Tasks included but not limited to, Administer treatments as ordered and monitor of effectiveness, date initiated 11/23/24. Follow the facility policies/protocols for the prevention/treatment of skin breakdown, date initiated 11/23/24. Review of Resident #69's clinical record indicated he/she was being seen by the wound consultant weekly beginning in 11/27/24. The 11/27/24 note indicated a pressure ulcer to the left heel, unstageable tissue type 100 % eschar (dead tissue). The wound consultant follow-up notes dated 12/2/24 indicated unstageable pressure ulcer left heel, Treatment recommendations: Wash with wound wash/cleanser. Pat dry. Apply skin prep to peri skin. Cover wound with Santyl/Ca (calcium) Alginate. Cover with ABD dressing and wrap with kerlix QD (once a day) and PRN (as needed). Review of wound consultant notes dated 12/9/24, 12/16/24, 12/27/24, 12/30/24, 1/6/25, 1/13/25, 1/26/25, 1/31/25, 2/3/25, 2/10,25, 2/18/25, 2/24/25, 3/3/25, 3/20/25, 4/7/25 indicated the left heel pressure ulcer as unstageable and had the same treatment recommendation; Wash with wound wash/cleanser. Pat dry. Apply skin prep to peri skin. Cover wound with Santyl/Ca (calcium) Alginate. Cover with ABD dressing and wrap with kerlix QD (once a day) and PRN (as needed). Review of the wound consultant follow-up note dated 4/14/25 indicated: Debridement (a removal of dead, damaged or infected tissue) performed today which patient tolerated well. There is healthy exposed muscle in wound base, making this a stage 4 pressure injury. Discussed on going treatment with nurse. Wounds: Pressure ulcer heel left stage 4, Plan: Treatment Recommendations: instruction: wash with wound wash/cleanser, pat dry, skin prep to peri skin. Apply medihoney, cover with ABD with kerlix wrap. Review of the wound consultant follow-up progress notes dated 4/21/25, 4/28/25, 5/5/25 and 5/12/25 all indicated the left heel ulcer as a stage 4 and the treatment recommendation instruction: wash with wound wash/cleanser, pat dry, skin prep to peri skin. Apply medihoney, cover with ABD with kerlix wrap. Review of the Medication Administration Record dated 4/1/25-4/30/25 did not indicate any treatment orders. Review of the Treatment Administration Record (TAR) dated 4/1/25 through 4/30/25 indicated the following treatment as administered: Pressure ulcer heel Left: Wash with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl to necrotic skin calcium alginate to wound, cover with ABD pad wrap with Kerlix daily, every day shift for wound care, start date 3/26/25. The TAR failed to indicate the wound consultant recommendation dated 4/14/25, for the Stage 4 pressure ulcer to Resident #69's left heel was provided as indicated. The TAR indicated the order to treat the unstageable pressure ulcer to Resident #69's left heel continued. Review of the Treatment Administration Record dated 5/1/25 through 5/13/25 indicated Pressure Ulcer Heel Left: wash with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl to necrotic skin calcium alginate to the wound, cover with ABD pad wrap with Kerlix daily was signed off as administered 5/1/25- 5/13/25 with the omission of 5/3/25. This treatment was for the unstageable pressure ulcer and not the treatment recommended by the wound consultant for the stage 4 pressure ulcer on Resident #69's left heel. Review of the MAR/TAR for April 2025 and May 2025 failed to indicate the treatment order for the stage 4 pressure ulcer to Resident #69's left heel was implemented until 5/14/25, resulting in 29 days without the recommended treatment by the wound consultant for Resident #69's stage 4 left heel pressure ulcer. During an interview on 6/4/25 at 9:00 A.M., Nurse #2 said Resident #69 had a pressure ulcer on his/her left heel and is seen weekly by the wound consultant. Nurse #2 said the nurse caring for the resident will do the wound rounds with the wound consultant. Nurse #2 said recommendations for treatment is made by the wound consultant and the ADON (Assistant Director of Nursing) or DON (Director of Nursing) obtain the order from the doctor or nurse practitioner (NP) and the treatment is entered as an order. Nurse #2 said the doctor and NP always agree with the recommendations made by the wound consultant, especially for Resident #69. Nurse #2 said treatments are completed as ordered and signed off on either the MAR or TAR after the treatment is done. Nurse #2 said Resident #69 does not refuse treatments but sometimes will take off the dressing and that is why she coverers it with a slipper sock. Nurse #2 said in April (2025) the wound consultant changed the treatment to Resident's #69's left heel pressure ulcer after it was debrided. Nurse #2 reviewed the TAR and MAR and said the treatment order stayed the same and was not changed in April as recommended. Nurse #2 said she knew the treatment was changed to medihoney. During an interview on 6/4/25 at 1:38 P.M., the DON said Resident #69 is followed by the wound consultant. The DON said any recommendation made by the wound consultant should be placed in the physician's orders and completed as ordered. The DON said the nurses who round with the wound consultant do not realize they are able to get an order from the doctor or NP and place the order in the medical record. The DON said the wound consultant is the person who assesses and knows how to treat a pressure ulcer and if orders are not followed or implemented there could be a potential for the wound to worsen. During an interview on 6/4/25 at 2:59 P.M. the wound consultant said she is a nurse practitioner and wound care specialist. The wound consultant said she rounds weekly on wounds and the nurse on the floor caring for the resident rounds with her most times. The wound consultant said when recommendations are made, she tells the nurse verbally, then I provide a note with who I have seen, and recommendations made and give it to the Director Nursing at the end of my rounding and the next day my full note would be uploaded in the electronic medical record. The wound consultant said she would expect the recommendations to be entered as physician's orders. The wound consultant said there are many factors on how a wound can heal and the dressing is the cherry on top. The wound consultant said off-loading, chronic conditions are factors for a wound to heal or worsen. The wound consultant said when she first met Resident #69 around the end of March 2025 or April 2025 the wound was unstageable and covered with necrotic tissue. The wound consultant said she then debrided the wound and determined the appropriate staging after the debridement of the left heel as a stage 4 pressure ulcer. The wound consultant said she changed the treatment at that time to treat the stage 4 open area on Resident #69's left heel. The wound consultant said the treatment for the unstageable pressure ulcer was Santyl which is an enzymatic to breakdown necrotic tissue and the calcium to manage any drainage from the wound. The wound consultant said once the wound was opened and clean the wound no longer needed Santyl, but the Santyl would not breakdown healthy skin. The wound consultant said she changed the treatment to medihoney as treatment for the left heel stage 4 pressure ulcer and was not aware that the treatment to the stage 4 left heel pressure ulcer was not implemented for nearly a month. During an interview on 6/4/25 at 4:22 P.M., Resident #69's nurse practitioner said the wound consultant has the expertise, not me to make recommendations for pressure ulcer treatments. The NP said she would follow the recommendations and expect the treatment to be entered as an order and provided by the nurse caring for Resident #69. During an interview on 6/5/25 at 10:57 A.M., the Medical Director, who is Resident #69's physician said orders are to be implemented after the wound provider rounds and makes recommendations. The MD said this has been identified as a problem at the facility with staff not following through. The MD said he would 100% follow the wound consultant recommendations for Resident #69's pressure ulcer on his/he left heel, as this is their area of knowledge. The MD said the risk of not implementing the wound consultant recommendations could lead to infection, worsening or neglect. The MD said the wound consultant notes are sent to him for review and that he was not aware the treatment recommendation was not implemented as an order for Resident #69's left heel stage 4 pressure ulcer. 4b. Review of Resident #69's Treatment Administration Record (TAR) dated 2/1/25 through 2/28/25 indicated the following order: Pressure Ulcer Heel left, wash with wound cleanser, pat dry, apply skin prep to peri skin, calcium alginate to wound, cover with ABD pad wrap with Kerlix daily and PRN (as needed). Further, review of the TAR indicated the treatment was not signed off as competed on 2/3/25, 2/4/25, 2/6/25, 2/17/25, 2/19/25, 2/20/25, 2/24/25, and 2/27/25. Eight pressure ulcer treatments were not documented as provided out of 28. Review of the clinical record indicated progress notes dated 2/15/25 and 2/22/25 that Resident #69 refused the treatment. These dates did not correspond with the days that were left blank on the TAR. There were no progress notes dated for the eight blank days on the TAR. During an interview on 6/4/25 at 9:00 A.M., Nurse #2 said nurses provide wound treatments, date and sign the dressing, them sign off in the TAR as completed. Nurse #2 said if for any reason the treatment is not provided then a progress note should be written. Nurse #2 said the TAR should not be left blank. Nurse #2 reviewed the February TAR and said 8 treatments were blank and not signed off as completed. During an interview on 6/4/25 at 1:38 P.M., the Director of Nursing said if the TAR is blank then there is no documentation to support the treatment was completed. 5. Resident #21 was admitted to facility in October 2018 with diagnoses including stroke, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #21 is severely cognitively impaired and totally dependent on staff for all activities of daily living. On 6/3/25 at 7:38 A.M., the surveyor observed Resident #21 resting in bed on an air mattress (a specialty mattress utilized to reduce pressure to the body.) Resident #21 appeared thin, frail and was unable to engage in the interview process. Review of the clinical record indicated Resident #21 had pressure injuries on his/her left hip and sacrum and was being followed by the Wound Consultant. Review of the Wound Consultant note dated 5/26/25 indicated: Patient laying in bed. Seen with nurse today. Patient has new DTI (deep tissue injury) to gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum,) and left hip pressure injury has re-occurred. Patient unable to provide history. Nurse does not recall seeing these wounds a few days ago when last caring for patient. Treatment Recommendations: Instruction: Wash with wound cleanser, cover with bordered foam dressing. Change daily and PRN. Review of Resident #21's physician orders failed to indicate any treatment order related to his/her newly developed DTI on his/her gluteal cleft. During an interview on 6/3/25 at 11:50 A.M., Nurse #3 said that Resident #21 has pressure injuries on his/her sacrum and hip. Nurse #3 did not say Resident #21 had a wound to his/her gluteal cleft. During an interview on 6/4/25 at approximately 8:15 A.M., Nurse #1 said that Resident #21 has wounds on his/her hip, sacrum and possibly on his/her heel but it may have healed at this point. During an interview on 6/4/25 at 9:54 A.M., Certified Nursing Assistant (CNA) #1 said that she is assigned to care for Resident #21 and he/she needs two staff for assistance with turning and positioning. CNA #1 said that Resident #21 has two pressure areas and pointed to the left and right hip. On 6/4/25 at 10:01 A.M., the surveyor observed Nurse #1 (with the assistance of Nurse #2) complete Resident #21's wound treatments. Nurse #1 said that Resident #21 has two areas; one on the right hip which requires skin prep and an unstageable area to his/her sacrum which required cleansing with calcium alginate with silver and to cover with a border foam dressing. At 10:04 A.M. Nurse #1 checked the orders and returned with supplies to perform the dressing changes. During the treatment, Resident #21's gluteal cleft was observed to be red, fragile, and did not have a dressing on it. Nurse #1 said that there was no treatment in place for that area and Nurse #2 said that the area had been open in the past for Resident #21, although it was not currently an open area. During an interview on 6/4/25 at 10:21 A.M., Nurse #1 said that the recommended treatment made by the Wound Consultant for Resident #21's gluteal cleft should have been implemented. Nurse #1 said she was not sure who is responsible for reviewing the wound treatment recommendations and entering them into the computer as the unit does not currently have a Unit Manager. Nurse #1 said that when treatment recommendations are not implemented, there is a risk of a wound worsening and infection. During an interview on 6/4/25 at 1:18 P.M., the Director of Nursing (DON) said that the Wound Consultant rounds weekly with the floor nurses who are then responsible for inputting the treatment recommendations into the electronic health record as orders. The DON said that the Wound Consultant notes are automatically uploaded to the resident record and she will also review them and input the treatment orders if they are missing. The DON was not aware a treatment and dressing was not in place for Resident #21 newly acquired DTI at the time of the surveyor's observation. During an interview on 6/5/25 at 10:52 A.M., the Medical Director said that he was not aware that recommendations from the wound consultant were not being implemented by the facility. He said that his expectation is that recommendations are reviewed with the attending providers and implemented as recommended. He said that he would not go against the recommendations of the wound consultant because they are the experts in wounds, and he is not. He said that not implementing treatment recommendations as ordered could result in infection, sepsis, and worsening wounds. He said wounds are a big risk factor for residents and that nurses and medical staff need to stay on top of them and ensure proper treatment. Refer to F726, F867 Based on observation, record review and interview, the facility failed to ensure five Residents (#24, #61, #30, #69 and #21) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 24 Residents. Specifically, 1. For Resident #24 the facility failed to implement recommendations from the Wound Consultant over a three-month period resulting in the deterioration of a pressure wound from a stage 2 pressure wound to an unstageable pressure wound. 2. For Resident #61 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. 3. For Resident #30 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. 4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant recommendation, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. 5. For Resident #21 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, Revised October 2010, indicated the following: -The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer(s). -The physician will authorize pertinent treatment orders related to wound treatments, including pressure reduction surfaces, wound cleaning and debridement approaches, dressings (occlusive, absorption, etc.) and application of topical agents. 1. Resident #24 was admitted to the facility in January 2023 with diagnoses that included fusion of spine, cervical region, protein calorie malnutrition and iron deficiency anemia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has one stage 1 pressure ulcer, and one unstageable pressure ulcer, neither of which were present on admission. The MDS dated [DATE] did not assess for behaviors, however, review of an MDS assessment dated [DATE] indicated that the behavior of rejection of care was not present. Review of the most recent Norton Assessment (an assessment to determine risk for skin breakdown), dated 5/28/25, indicated a risk score of 18, indicating low risk for skin breakdown. Review of Resident #24's active risk for skin breakdown care plan indicated the following, dated as revised 5/11/23: Skin: [Resident] has OCC. (occasional) incontinence r/t (related to) Confusion, Impaired Mobility, Physical limitations, with a goal that indicated, [Resident] will remain free from skin breakdown due to incontinence and brief use through the review date. Review of the wound consultant note, dated 2/24/25, indicated the following: -With facility-acquired pressure ulcers. PU2 (pressure ulcer) to proximal lower back and distal lower back over the vertebrae. No other areas of concern. The patient denies pain. No signs or symptoms of infection were noted. Tx (treatment) plan is added. -Treatment recommendations for both areas: #3 Pressure ulcer Lower Back proximal and #4 Pressure ulcer Lower Back distal -Measurements for Pressure ulcer to the lower back proximal were 0.8 centimeters (cm) x 0.6 cm x 0.1 cm in depth, and for the pressure ulcer to the lower back distal were indicated as 1 cm x 2.2 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to peri skin. Cover with Xeroform, Silicone bordered dressing QD (daily) and PRN (as needed). Frequent repositioning. Off Load pressure Q2hrs (every two hours). *Recommend Vitamin C 500mg, Zinc 50mg and protein supplement. Review of active and discontinued physician's orders failed to indicate that recommendations were implemented as indicated in the wound consultant note, and indicated the following orders: -Santyl (a prescription medication that removes dead tissue from wounds) Ointment 250 unit/gm (gram) (Collagenase) Apply to Proximal lower back topically every day shift related to pressure ulcer of unspecified site, stage 2, Cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing daily & PRN AND Apply to proximal lower back topically every 24 hours as needed for dislodgement or soiled dressing, cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing, dated as active from 2/26/25 through 3/21/25. [sic] -Santyl Ointment 250 unit/gm (Collagenase) Apply to distal lower back topically every day shift related to pressure ulcer of unspecified site, stage 2, cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then then silicone bordered dressing. Change daily and PRN AND Apply to distal lower back topically every 24 hours as needed for dislodgement or soiled dressing Cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing, dated as active from 2/26/25 through 3/21/25. [sic] Review of the medical record failed to indicate that the recommendations for offloading the wounds, Vitamin C or Zinc were implemented. The medical record further indicated that the Resident was already receiving protein supplementation, prior to the recommendation. Review of the medical record failed to indicate that the care plan was updated to indicate actual skin breakdown and that new interventions for repositioning or offloading were implemented in the plan of care for Resident #24. Review of the wound consultant note, dated 3/20/25, indicated the following: -#4 Pressure ulcer Lower Back distal- stage 2 (stage 2 pressure ulcer) -Measurement: 2 cm x 1 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to periskin. Cover with Xeroform, Silicone bordered dressing QD and PRN. Frequent repositioning. Off Load pressure Q2hrs. *Recommend Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of the medical record failed to indicate that any recommendations were implemented following the Wound Consultant visit. Review of discontinued physician's orders indicated the following: -Cleanse unstageable wound lower spine with NS. Pat dry. Apply skin prep every shift May apply ABD over lower spine wound for comfort, dated 3/21/25, and active until 4/17/25, (which did not match the recommendations from the Wound Consultant). Review of the wound consultant note, dated 3/31/25, indicated the following: -PU2 to lower distal back is improving to this week. PU2 to lower proximal back has resolved. -Treatment plan is updated. Nursing aware of wound assessment and treatment plan. No new skin concerns were noted. The patient denies pain. No signs or symptoms of infection were noted. -#4 Pressure ulcer Lower Back distal- Stage 2 -Measurement: 1.7 cm x 0.5 cm x .01 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to periskin. Cover with Xeroform, Silicone bordered dressing QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of discontinued physician's orders indicated the following: -Cleanse unstageable wound lower spine with NS. Pat dry. Apply skin prep every shift May apply ABD over lower spine wound for comfort, dated 3/21/25, and active until 4/17/25, (which did not match the recommendations from the Wound Consultant). Review of the wound consultant note, dated 4/28/25, indicated the following: -Patient is being seen for evaluation and treatment recommendation regarding lower back pressure injuries. -Patient was seen with nurse today. He/She denies concerns. The proximal pressure injury to his/her lower back has reopened since the last visit. He/She denies pain to the site and tells me that the wound comes and goes because the curvature of his/her spine. He/She reports that offloading helps. There are no signs or symptoms of infection. The distal pressure injury to the low back is improved. No other concerns noted. Discussed ongoing treatment plan with nurse. #3 Pressure ulcer Lower Back proximal (re opened)- stage 2 -Measurements: 1 cm x 0.5 cm x 0.2 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Cover with silicone foam dressing. Change QD and PRN. Frequent repositioning to offload bony prominence. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. -#4 Pressure ulcer Lower Back distal- stage 2 measurement: 1.2 cm x 0.6 cm x 0.1 cm in depth- moderate serous drainage. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Cover with silicone foam dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of the medical record failed to indicate that any recommendations were implemented from the Wound Consultant visit. Further review of the medical record failed to indicate that any dressing changes or wound care were provided, beginning on 4/17/25. Review of the wound consultant note, dated 5/19/25, indicated the following: -Patient is being seen for evaluation and treatment recommendation regarding lower back pressure injuries. -Patient seen sitting in WC. He/She denies pain or concerns related to wound care. Wounds are improving. No new areas of concern. Treatment plan updated and discussed with nurse. -#3 Pressure ulcer Lower Back proximal- stage 2 -Measurement: 0.5 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning to offload bony prominence. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] -#4 Pressure ulcer Lower Back distal- stage 2 measurement: 1 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. Review of the medical record failed to indicate that any recommendations were implemented from the Wound Consultant visit. Further review of the medical record failed to indicate that any dressing changes or wound care were provided, beginning on 4/17/25. Review of the wound consultant progress note, dated, 5/26/25 indicated the following: -Pressure ulcer to distal lower back is deteriorating while pressure ulcer to proximal lower back continues to improve. Stage 2 PU to distal lower back has changed into unstageable PU. Patient denies pain. No new areas of concern or s/s (signs and symptoms) of infection. Treatment plan updated and discussed with nurse. -#3 Pressure ulcer Lower Back proximal- stage 2 -Measurement: 0.5 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. -#4 Pressure ulcer Lower Back distal- unstageable pressure ulcer measurement: 2 cm x 1.5 cm x 0.2 cm in depth- moderate serous drainage. 90% Slough (in wound bed). Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply santyl to wound followed by cut-to-fit piece of moist gauze. Cover with bordered foam dressing. Change QD and PRN. Frequent repositioning to offload bony prominence with pillow behind back on wheelchair. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. Review of the May 2025 Medication Administration Record and Treatment Administration Record failed to indicate that the treatments for either pressure ulcer were initiated and implemented as per the recommendations from the wound consultant. Further review of the medical record indicated that the Zinc 50 mg recommendation was not implemented until 5/31/25, 96 days after it was initially recommended to aid in wound healing. Review of active physician's orders as of 6/3/25 indicated the following: -Zinc 220 mg daily, dated 5/31/25, initially recommended in wound recs on 2/24/25, 96 days after it was recommended to aid in wound healing. -Cleanse wound on back with NS (Normal saline) and apply skin prep and optifoam dressing daily, dated 3/31/25. (This order was entered as ancillary and was not scheduled on any Medication or Treatment Administration Record, therefore there is no sign off to indicate that the order was completed or implemented. Review of nursing progress notes also failed to indicate that the treatment was provided). Review of active and discontinued physician's orders failed to indicate that Vitamin C, offloading of the pressure areas and frequent repositioning were ever initiated or monitored per the Wound Consultant recommendations beginning 2/24/25. Review of the medical record failed to indicate that from 4/17/25 to 6/3/25 a wound treatment order was completed or implemented as recommended by the wound consultant. Review of the medical record from 5/19/25 through 5/26/25, when the pressure ulcer to the distal lower back was documented as deteriorated and now assessed as an unstageable wound by the Wound Consultant, failed to indicate that any treatments were in place or implemented, and failed to indicate refusal of any skin wound treatments. Review of the medical record also failed to indicate that the recommendations from 5/26/25 were implemented until 6/4/25 when the surveyor brought it to the attention of the facility. During an interview and observation on 6/3/25 at 12:35 P.M., Resident #24 said he/she has a wound on his/her back, but they are no longer providing treatments to it. The surveyor requested to observe the wound, and the Resident declined for today. The surveyor asked if they could return tomorrow and re-address and the Resident said that would be fine but that at this time, he/she wants to lay down. During this observation, the resident was lying in bed, on his/her back, without any offloading measures in place. During an interview on 6/4/25 at 7:34 A.M., Nurse #5 said that she often takes care of Resident #24. She said Resident #24 has no wounds and no orders for any dressings or offloading/ repositioning measures. She said she has not completed any wound treatment or dressing changes on Resident #24 recently. She reviewed the medical record and confirmed, there are no ordered treatments on the Treatment Administration Record. During an interview on 6/4/25 at 7:45 A.M., Certified Nurse Aide #2[TRUNCATED]

Based on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control. Findings include: Review of the facility policy titled Infection Control Policy and Procedure, undated, indicated the following: -To help prevent the development and transmission of communicable disease and infection in the Facility and to ensure that the Facility: -Designates one or more individual(s) as the Infection Preventionist (IP) who are responsible for the facilities IPCP. Establishes Facility wide systems for the prevention, identification, investigation, and control of infections of residents, staff (which includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, and students in the facilities nurse aid training programs or from affiliated academic institutions) and visitors. This includes an ongoing system of surveillance designated to identify possible communicable diseases or infections before they can spread to other persons in the Facility and procedures for reporting possible incidents of communicable diseases or infections. -Infection Preventionist a. IPCP should develop and implement IPCP with leadership support and accountability via the participation of the medical director consulting pharmacist nursing and administrative leadership utilizing and working collaboratively with these team members. The IP should review and approve infection prevention and control training topics and content as well as ensure facility staff are trained on the IPCP. Review of the Facility assessment dated [DATE], indicated the following: Staff type/Plan: Infection Control and Prevention. 1 Full time Infection Control/ADON -weekdays and weekends if needed. Review of the facility document titled Designation of Infection Preventioninst undated, failed to include any information and was left blank. During an interview on 6/5/25 at 9:10 A.M., the Director of Nursing (DON) said she started in this role at the end of April 2025. The DON said she does not have the required infection control certification, and the facility does not have an approved Infection Preventionist working in the facility. The DON said she discussed this with the Administrator and [NAME] President of Clinical Operations and said she is trying her best to monitor the infections. During an interview on 6/5/25 at 9:56 A.M., the Administrator said he was aware that the facility did not have an infection preventionist in the building. During an interview on 6/5/25 at 12:54 P.M., the [NAME] President of Clinical Operations said the facility has been without an Infection Preventionist and said they had a staff member helping with the role but is no longer here.

2. Resident # 63 was admitted to the facility in [DATE] with diagnoses including hypertension. A review of the most recent Minimum Data Set (MDS) assessment, dated [DATE] failed to indicate a Brief Interview for Mental Status (BIMS) score. A review of Resident #63's care plan initiated [DATE] indicated that Resident #63 makes his/her own health decisions. A review of Resident #63's [DATE] physician's orders indicated the following: -Incision right hip. Start date [DATE]. -Wound vacuum settings 125 mmhhg (milliliters of mercury), change Monday-Wednesday-Friday. Start date [DATE]. -Cefazolin Sodium injection solution, use 2 grams intravenously every 8 hours for surgical incision until [DATE]. Start date [DATE]. On [DATE] at 8:46 A.M., the surveyor observed Resident #63 in bed. There was no Enhanced Barrier Precautions (EBP) signage and a Personal Protective Equipment (PPE) cart prior to room entry. On [DATE] at 8:04 A.M., 9:25 A.M., and 2:15 P.M., the surveyor observed Resident #63 in bed. There was no Enhanced Barrier Precautions (EBP) signage and a Personal Protective Equipment (PPE) cart prior to room entry. On [DATE] at 4:58 P.M., the surveyor observed Nurse #6 hanging the intravenous (IV) line. Nurse #6 was wearing gloves only, no other PPE. During an interview on [DATE] at 4:58 P.M., Nurse #6 said the Resident has a (Peripherally Inserted Central Catheter) PICC line and does not require any precautions. During an interview on [DATE] at 8:22 A.M., the Director of Nurses said EBP signage and a PPE cart should be available prior to entering the Resident's room because he/she has a PICC line and a right hip surgical incision with a wound vacuum. She said EBPs should be in place to prevent infections.3. Review of the facility policy titled Infection Control Policy and Procedure, undated, indicated the following: -To help prevent the development and transmission of communicable disease and infection in the Facility and to ensure that the Facility: I. Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. This would include revision of the IPCP as national standards change. II. Designates one or more individual(s) as the Infection Preventionist (IP) who are responsible for the facilities IPCP. Establishes Facility wide systems for the prevention, identification, investigation, and control of infections of residents, staff (which includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, and students in the facilities nurse aid training programs or from affiliated academic institutions) and visitors. This includes an ongoing system of surveillance designated to identify possible communicable diseases or infections before they can spread to other persons in the Facility and procedures for reporting possible incidents of communicable diseases or infections. -An antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. -A system for recording incidents identified under the Facility's IPCP and the corrective actions taken by the Facility. III. Infection Preventionist -IPCP should develop and implement IPCP with leadership support and accountability via the participation of the medical director consulting pharmacist nursing and administrative leadership utilizing and working collaboratively with these team members. The IP should review and approve infection prevention and control training topics and content as well as ensure facility staff are trained on the IPCP. Review of the Facility assessment dated [DATE], indicated the following: Diseases /conditions, physical and cognitive disabilities. -Infectious Diseases: COVID-19, Skin and Soft Tissue Infections, Respiratory Infections, Tuberculosis, Urinary Tract Infections, Infections with Multi-Drug Resistant Organisms (MDRO), Septicemia, Viral Hepatitis, Clostridium difficile, Influenza, Scabies, Legionella's. -Resident Support/Care Needs: Infection prevention and control. Identification and containment of infections, prevention of infections. COVID-19 CDC/DPH (Center of Disease Control / Department of Public Health) protocols. Management and preventions of MDRO's. Consult with LBOH (Local Board of Health) and MA (Massachusetts) Epidemiology when required and as needed. -Management of Medical Conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failures, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infectious such as UTI (Urinary Tract Infection) and gastroenteritis, pneumonia and hypothyroidism. -Evaluation of Infection Prevention and Control Program: The facility looks at infection control through its morning clinical review. Individuals are tracked and monitored on the line listings. Line listing review identifies trends. Information is sent to the lab. This information is reviewed by the lab and processed on an infection control report which is returned to the facility. Infection control is revived monthly and quarterly, at QAPI (Quality Assurance Performance Improvement Plan) meetings and as needed through ad-hoc meetings if trends are identified. The infection control review includes nursing, administration, medical director, and lab/x-ray provider. All staff is educated on infection control standards. The facility partners with vendors who educate and uphold infection control standards. During the survey period the surveyor requested infection control program information for tracking infections, including line listings and reporting data. The facility failed to have any documented information related to tracking and reporting of infections in the facility. Further review indicated the facility failed to have any documented information for the months of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], February 2025, [DATE], [DATE], [DATE], [DATE]. During the course of the survey the facility was unable to provide surveillance data and documentation of follow-up activity in response to the active antibiotic use in the facility. Review of the electronic Antibiotic Order Listing report dated [DATE], indicated the following prescribed antibiotics for the following infections: [DATE] Antibiotics for skin infections. [DATE] Antibiotics for leg wound infections, Eye infections, Urinary Tract Infections, Pneumonia, Skin infections. [DATE] Antibiotics for Clostridium difficile (C.diff.)- (severe diarrhea that is highly contagious), Right Hip wound infection, Head Lice infection, Urinary Tract Infections, Pneumonia, Hand infection, Bullous Pemphigoid (blisters and itching on skin). [DATE] Antibiotics for Wound infections, Eye infection, Urinary Tract Infections, Skin abscess. February 2025 Antibiotics for Pneumonia, Abscess, Bacterial Infections. [DATE] Antibiotics for Pneumonia, Bacterial Infections, Cellulitis, COVID-19, Urinary Tract Infections. [DATE] Antibiotics for skin rashes, Pneumonia. [DATE] Antibiotics for wound infections. [DATE] Antibiotics for Urinary Tract Infections, Skin Infections. [DATE] COVID +, C.diff +, Right Toe infection, Urinary Tract Infections, Pneumonia. During an interview on [DATE] at 9:15 A.M. the Director of Nurses (DON) said infections and surveillance of infections should be tracked, monitored, documented and reported and said the facility does not have an active Infection Preventionist in place and said she does not have any line listings in place. The DON said she does not know the rate of infections and said she has no data available and relies on what is reported to her by nursing staff. The DON said she is new to the facility and started in [DATE] and said she is unaware of the infections and has no information available regarding tracking, surveillance or outbreak information available. The DON said she does not have any training or certification completed and was unable to provide the surveyors with proof of certification of anyone overseeing the program. During an interview on [DATE] at 9:56 A.M., the Administrator said the Infection Control program should be implemented and followed and said he is not aware of the infections in the building and said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be followed. During an interview on [DATE] at 12:50 P.M., the [NAME] President of Clinical Operations said the facility has been without an Infection Preventionist and said she did not conduct any infection control tracking, reporting, surveillance or follow-up activity within the facility and said it is her expectation that the Infection Prevention and Control program is managed daily. The [NAME] President of Clinical Operations said they do not have an infection preventionist in the building. 4. Review of the facility policy titled, Legionella Water Management Program to Reduce Growth and Spread dated [DATE], indicated the following: -The Facility will identify and manage hazardous conditions that support growth and spread of Legionella. -Water Management Program Team will include the facility Infection Prevention, Director of Maintenance, Administrator and other members of the safety committee. The Facility must conduct a risk assessment to identify where the Legionella and other opportunities for waterborne pathogens could grow and spread in facility water system and assess how much risk the hazardous condition in those water system pose. -Review the elements of the water management program at least once a year to make sure the program is running as designed and is effective. -Refer to flow diagram: Areas where Legionella could grow and spread. Review of the Water Management documents submitted during survey, failed to include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread and did not contain measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. During an interview on [DATE] at 1:59 P.M., the Maintenance Director said he has no involvement with the Legionella program and said it is managed by the Regional Maintenance Director. During an interview on [DATE] at 12:49 P.M., the Administrator said the facility is required to have a program in place to monitor for Legionella and said he expects it to be implemented and followed. The Administrator said he does not have any information regarding the program and said it is managed by the Regional Maintenance Director. During an interview on [DATE] at 1:13 P.M., the Regional Maintenance Director said they follow the facility policy and test if needed and said he is not aware of any flow diagram and said the Facility has not had any issues. Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Residents (#21 and #63) out of a total sample of 24 Residents. Specifically, 1. For Resident #21 the facility failed to implement or maintain Enhanced Barrier Precautions and hand hygiene during a wound dressing treatment. 2. For Resident #63 the facility failed to implement Enhanced Barrier Precautions. 3. The facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. 4. The facility failed to have a documented water management program. Findings include: Review of the Centers for Disease Control (CDC) website indicated the following, dated [DATE]: -Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Resident #21 was admitted to the facility in [DATE] with diagnoses that included cerebral infarction and need for assistance with personal care. Review of Resident #21's most recent Minimum Data Set (MDS) Assessment, dated [DATE], indicated that the Resident was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severe cognitive impairment. Further review of the MDS indicated that the Resident has one or more unhealed pressure ulcer. The Resident is coded as having one stage 3 and one stage 4 pressure ulcer that were both present on admission. Review of Resident #21's active physician's orders indicated the following: -Unstageable pressure ulcer sacrum: Cleanse wound and peri-wound area with wound cleanser, pat and dry. Apply Calcium alginate with silver. Cover with bordered Form dressing. Daily And PRN (as needed), dated [DATE]. -left hip dry scab: apply Skin prep Topically every day and evening shift, dated [DATE]. Review of Resident #21's most recent wound consultant note, dated [DATE], indicated the following: -A stage 4 pressure ulcer to the sacrum, measuring 3 centimeters (cm) x 3.9 cm x 0.2 cm in depth. -A stage 3 pressure ulcer to the gluteal cleft, measuring 6 cm x 4 cm x 0.1 cm in depth. During a wound dressing observation on [DATE] at 10:01 A.M., Nurse #1 entered Resident #21's room. There were no signs on the doorway or door to the Resident's room indicating a need for any EBP. Nurse #1 and the assisting nurse both washed their hands and applied gloves upon entering the room. Neither nurse donned a gown. Nurse #1 removed a dressing from Resident #21's left hip. Nurse #1 then removed her gloves and without performing hand hygiene donned a new pair of gloves. She applied skin prep to the area of the wound, removed her gloves, and again, without performing hand hygiene, applied another pair of gloves to apply the covering over the wound. Nurse #1 then changed her gloves without performing hand hygiene and performed the treatment to Resident #21's sacrum. Nurse #1 removed the old dressing, changed her gloves without performing hand hygiene and then completed the wound dressing. During an interview on [DATE] at 10:21 A.M., Nurse #1 said that residents who have wounds should be on EBP. She said she should have worn a gown to change the dressing on Resident #21, but she did not. She said that the Infection Preventionist is responsible for managing who is on EBP, and residents on EBP would have a sign on the door or doorway of their room and a physician's order to utilize them. She also said that she should have sanitized her hands in between all her glove changes, but she did not. She said that not implementing EBP places the resident at risk for infection. During an interview on [DATE] at 1:37 P.M., the Director of Nurses (who is also covering as the Infection Preventionist at this time) said that she would expect that a resident who has wounds is on EBP. She said she would expect that when nurses are providing wound care, they are wearing a gown and gloves. She said that not implementing EBP would pose a risk for infection. During an interview on [DATE] at 11:15 A.M., the Medical Director said that he was not aware that EBP were not being implemented and would expect that to prevent the spread of infections, staff would implement EBP and other infection control procedures.

Based on record review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship, dated as revised December 2016 indicated the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. -The purpose of our Antibiotics Stewardship Program is to monitor the use of antibiotics in our residents. -Orientation, training and education of staff will emphasize the importance of Antibiotic Stewardship and will include how appropriate use of antibiotics affects individual residents and the overall community. -Training and education will include emphasis on the relationship between antibiotic use and: a. Gastrointestinal disorders; b. Opportunistic infections (e.g., C.difficile, candida albicans, etc.). c. Medication interactions; and d. The evolution of drug resistant pathogens. During the survey period the surveyor requested infection control line listings and antibiotic stewardship information. The facility failed to have any documented information related to tracking, follow up or review with the physician or nurse practitioner following the initiation of the antibiotics for 7 out of 7 active physician antibiotic orders prescribed. Further review indicated the facility failed to have any documented information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025. During an interview on 6/5/25 at 9:12 A.M. the Director of Nurses (DON) said antibiotics should be tracked, documented and reported and said the facility does not have an active Infection Preventionist in place and said she is told in morning meeting if someone is on an antibiotic but has not been tracking or monitoring specific data regarding the antibiotic stewardship program. The DON said she does not have any line listings in place. During an interview on 6/5/25 at 9:52 A.M., the Administrator said the Infection Control and Antibiotic Stewardship program should be tracked and followed and said the facility has been without an Infection Preventionist and said he had a staff member helping but not full time and said she is no longer here.

Based on interview and records reviewed, the facility failed to have sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Specifically, the facility failed to maintain sufficient staffing according to the facility assessment and facility staffing requirements. Findings include: Review of the Facility Assessment Tool, dated and reviewed by the facility in May 2024, indicated the following staffing ratios for Nurses and Certified Nursing Aides (CNA's): -4 Licensed Practical Nurses (LPN) / Registered Nurses (RN) Full time days - weekdays and weekends. -4 LPN / RN Full time evening - weekdays and weekends. -2 LPN / RN Full time nights - weekdays and weekends. -8 CNA's Full time days - weekdays and weekends. -8 CNA's Full time evenings - weekdays and weekends. -4 CNA's Full time nights - weekdays and weekends. During the recertification survey the surveyors' observed concerns with showers not being provided and low staffing reports from staff and residents. During the initial tour of the facility on 6/3/25, there were multiple concerns reported to the surveyors by residents who expressed concerns about needing more staff in the building. Some of these interviews included: - One resident said, They don't have enough staff and I haven't had a shower in weeks. - One resident further said There is not enough staff, especially on the weekends. There is no help. During an interview on 6/3/25 at 7:57 A.M., Resident #39 said that he/she had not received a shower in about 12 weeks. Resident #39 stated that it's not that he/she refuses, but that they aren't offering a shower to him/her. He/she said that it depends on who's working or how much staff they have. During the Resident Group meeting held on 6/4/25 at 3:30 P.M., residents said they do not always have enough staff. Residents said they know this because it takes longer to get someone to help with answering call lights. The residents reported concerns with all shifts and they need to wait to be assisted to the bathroom or other needs including showers. Ten out of 17 residents in attendance said they often wait over 25 minutes to get the assistance they need. Review of the Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 1, 2025 (October 1, 2024 - December 31, 2024) was reviewed. The facility's report triggered the following: Review of the PBJ Staffing Data Report, submitted by the facility for fiscal year (FY) Quarter 1: Dated 2025 (October 1 - December 31), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1. -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low. -No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours. Review of the weekend staff schedule, dated October 1, 2024, to December 31, 2024, indicated that the facility was staffed below their determined minimum necessary for Licensed Nurses and CNA's for seven weekends. The weekend staff schedules indicated the following staffing during this quarter: Review of the actual daily schedule report for Saturday 10/19/24 indicated the following: -4 LPN / RN Day shift: Only 3 Nurses scheduled. -4 LPN / RN Evening shift: Only 2 Nurses scheduled. -8 CNA's Day shift: Only 6 CNA's scheduled. -8 CNA's Evening shift: Only 5 CNA's scheduled. Review of the actual daily schedule report for Saturday 11/2/24 indicated the following: -4 LPN / RN Day shift: Only 3 Nurses scheduled. -4 LPN / RN Evening shift: Only 2 Nurses scheduled. -8 CNA's Day shift: Only 7 CNA's scheduled. -8 CNA's Evening shift: Only 6 CNA's scheduled. Review of the actual daily schedule report for Sunday 11/3/24 indicated the following: -4 LPN / RN Day shift: Only 3 Nurses scheduled. -8 CNA's Evening shift: Only 6 CNA's scheduled. Review of the actual daily schedule report for Saturday 11/9/24 indicated the following: -8 CNA's Evening shift: Only 5 CNA's scheduled. Review of the actual daily schedule report for Sunday 11/10/24 indicated the following: -8 CNA's Day shift: Only 7 CNA's scheduled. -8 CNA's Evening shift: Only 6 CNA's scheduled. -4 CNA's Nights shift: Only 3 CNA's scheduled. Review of the actual daily schedule report for Sunday 12/1/24 indicated the following: -4 LPN / RN Evening shift: Only 3 Nurses scheduled. -8 CNA's Evening shift: Only 5 CNA's scheduled. Review of the actual daily schedule report for Sunday 12/15/24 indicated the following: -8 CNA's Evening shift: Only 5 CNA's scheduled. Further review of the weekend staff schedules continued to indicate the facility was staffed below their determined minimum necessary of Licensed Nurses and CNA's on four weekends. The weekend staff schedules indicated the following staffing: Review of the actual daily schedule report for Saturday 5/24/25 indicated the following: -4 LPN / RN Day shift: Only 1 Nurse scheduled. -4 LPN / RN Evening shift: Only 1 Nurse scheduled. -2 LPN / RN Night shift: Only 1 Nurse scheduled. -8 CNA's Day shift: Only 5 CNA's scheduled. -8 CNA's Evening shift: Only 5 CNA's scheduled. Review of the actual daily schedule report for Saturday 5/25/25 indicated the following: -4 LPN / RN Day shift: Only 2 Nurses scheduled. -4 LPN / RN Evening shift: Only 1 Nurse scheduled. -2 LPN / RN Night shift: Only 1 Nurse scheduled. -8 CNA's Day shift: Only 5 CNA's scheduled. -8 CNA's Evening shift: Only 4 CNA's scheduled. Review of the actual daily schedule report for Saturday 5/31/25 indicated the following: -4 LPN / RN Day shift: Only 2 Nurses scheduled. -4 LPN / RN Evening shift: Only 1 Nurse scheduled. -2 LPN / RN Night shift: Only 1 Nurse scheduled. -8 CNA's Day shift: Only 4 CNA's scheduled. -8 CNA's Evening shift: Only 5 CNA's scheduled. Review of the actual daily schedule report for Sunday 6/1/25 indicated the following: -4 LPN / RN Day shift: Only 3 Nurses scheduled. -4 LPN / RN Evening shift: Only 1 Nurse scheduled. -2 LPN / RN Night shift: Only 1 Nurse scheduled. -8 CNA's Day shift: Only 7 CNA's scheduled. -8 CNA's Evening shift: Only 5 CNA's scheduled. During an interview on 6/04/25 at 8:17 A.M., a staff member on the second floor unit said, there is not enough staff, and they only have three CNA's scheduled. If one CNA goes on break and the other two are assisting a resident with transfers, then there is no one. The staff member said sometimes care/showers don't get completed because there is not enough staff. The staff member said the schedule will look good and staffed appropriately but it's not accurate of the number of staff in the building. During a telephone interview on 6/4/25 at 9:43 A.M., Certified Nurse Assistant (CNA) #2 said the facility has been short staffed often during the days and on the evening shift for a long time. CNA #2 said it is hard to find help to get residents up and showered because residents might need two or three staff to assist them. During an interview on 6/4/25 at 9:46 A.M., Nurse #7 said they are very short staffed and not enough CNA's are scheduled to care for the Residents that need help with showers, and care and said there is not enough staff to help with transfers. Nurse #7 said weekend shifts often run with 2-3 CNA's and said she had to stay late after a double shift because staff did not come in and no one came in to relieve her. Nurse #7 said she is always late with her medications because she needs to stop and help with care needs to keep the Residents safe. Nurse #7 said when staff go on break the Residents are left with 1-2 CNA's. During an interview on 6/5/25 at 8:24 A.M., the Human Resources Director who is also the Scheduler said she manages the schedule for the two units in the facility, and each unit requires 2 Nurses and 4 CNA's during the day shift, 2 Nurses and 4 CNA's during the evening shift, and 1 Nurse and 2 CNA's during the night shift. The Staff Scheduler said there have been staffing issues and said they have been running low and asking staff to pick up extra shifts to cover the staffing needs. During an interview on 6/5/25 at 8:50 A.M., the Director of Nurses (DON) said she expects the facility to be staffed appropriately and said a lot of staff will work double shifts or pick up shifts if we are low. The DON said they have been working on recruiting and having to use agency staff because they are running low. The DON said she has discussed the concerns with Administration. During an interview on 6/5/25 at 9:54 A.M., a staff member on the second-floor unit said there is not enough staff and only three CNA's are scheduled on the unit; (been like that for a couple months). When we only have three, we can't everything done, can't give showers if they're scheduled or requested. The residents aren't getting the care they need. Couldn't give any showers yesterday because there was not enough staff. During an interview on 6/5/25 at 12:04 P.M., a staff member on the second-floor unit said, there is not enough staff and things aren't getting done, management does not listen and thinks we are okay but we need more CNA's. During an interview on 6/5/25 at 11:26 A.M., the Administrator said it is his expectation that the building is staff appropriately as indicated in the facility assessment and said they have been facing staffing issues for quite some time. During an interview on 6/5/24 at 11:19 A.M., the Medical Director said the facility is understaffed and overworked and said he would like to see more seasoned nurses here and that they are doing the best they can. The Medical Director said there have been multiple Director of Nurses that have come and gone and its been a top priority for him to fix but change in leadership it keeps falling through. Refer to F726, F727, F730, F732, F867.

Based on interviews and record review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to change in condition of a wound and implement treatment recommendations, for 5 Residents (#24, #61, #30, #69, and #21), out of a total sample of 24 Residents. As a result of these failures, for Resident #24 the facility failed to implement recommendations from the Wound Consultant over a three-month period resulting in the deterioration of a pressure wound from a stage 2 pressure wound to an unstageable pressure wound. 2. Ensure that seven out of seven staff education records reviewed, had education and competencies and were completed and documented annually, per the Facility Assessment. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. -Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. -Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment: - Activities of Daily Living (ADL's): Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence in doing as much of these activities by himself/herself. - Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care, supporting resident independence in doing as much of these activities by him or herself. - Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. - Infection Prevention and Control: Identification and containment of infections, prevention of infections. - Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism. Review of the Facility Assessment, dated as reviewed with the QAA/QAPI committee, in May 2025, indicated the following: Staff training/education and competencies -Considerations: Training's will be conducted based on regulation, facility need and acuity or admissions. -Infection Control: Conducted on hire, annually and retraining as needed based on CDC (Center for Disease Control) and DPH (Department of Public Health) updates for COVD-19 [SIC] and other infections. Staff Competencies: Staff Type and Timing (on hire, annually, PRN (as needed), on demand) -Person Centered Care: All staff on hire, annually and as needed. -Activities of Daily Living All staff on hire, annually and as needed. -Infection Control: Hand Hygiene, Universal Precautions, Protective Equipment. -As needed with updates from DPH, CMS (Centers for Medicaid and Medicare Services) and CDC regarding COVID-19 following all CDC guidelines. -Medication Administration: All staff on hire, annually and as needed. -Measurements - Vitals and intake and output: All staff on hire, annually and as needed. -Resident Assessment: All staff on hire, annually and as needed. -Caring for Residents with dementia, Alzheimer's, and Cognitive Impairments. 8 hours of training upon hire and 4 hours upon annual recertification. -Caring for Residents with Mental and Psychosocial Disorders: All appropriate staff upon hire, annually and as needed. -Non-Pharmacological Management of Responsive Behaviors: All staff on hire, annually and as needed. -Caring for Residents with Trauma/PTSD (Post Traumatic Stress Disorder): All staff on hire, annually and as needed. -Clinical Competencies: All staff on hire, annually and as needed/As COVID-19 protocols change. -Evaluation of Infection Prevention and Control Program: Individuals are tracked and monitored on the line listings. Line listing review identifies trends. All staff is educated on infection control standards. The facility partners with vendors who educate and uphold infection control standards. Review of seven personnel files of actively working clinical nursing staff in the facility on 6/5/25 indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills and competency to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Seven out of seven employee records did not have the necessary training and clinical competencies on file upon hire or annually related to ADL', Falls, Change in Condition, Skin Integrity, Infection Control, Required Dementia Training and Medication Administration. During an interview on 6/5/25 at 8:52 A.M., the Director of Nurses (DON) said training and clinical competencies must be completed upon hire, annually and said she expects staff to have been checked off as passing a wound care competency and training before coming off orientation. The DON said she has not completed any training or competencies with clinical staff and said clinical staff should have the required clinical competences on file and annually including those listed in the facility assessment. During an interview on 6/5/25 at 9:38 A.M., the Administrator said it is his expectation that the clinical staff are trained appropriately and have the required completed clinical competencies and training on file according to the facility assessment. The Administrator said they have been without an Assistant Director of Nursing or Staff Educator since last fall and said they had a staff member helping out but she went on leave and he is not sure what training system is in place. During an interview on 6/5/24 at 11:19 A.M., the Medical Director said he would expect the facility is maintaining and keeping up with required trainings upon hire and annually as required and completing clinical competencies for all clinical staff. During an interview on 6/05/25 at 12:36 P.M., the [NAME] President of Clinical Operations said staff must have mandatory education and demonstrated clinical competencies completed upon hire and annually and said they know they need to improve and have not been able to complete the required training. REF F 867

Based on interview and records reviewed, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for seven days for the period of 10/1/24 to 12/31/24. Findings include: 1. Review of the PBJ Staffing Data Report, dated Quarter 1: 2025 (October 1 - December 31), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1. -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low. -No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours. Review of the as worked nursing schedule provided by the facility failed to indicate that a Registered Nurse worked for eight hours in the facility on the following days: -10/19/24 -11/2/24 -11/3/24 -11/9/24 -11/10/24 -12/1/24 -12/15/24 The facility failed to provide evidence through timecards or payroll information that an RN was onsite for 8 consecutive hours on the dates noted on the PBJ Staffing Data Report. Further review of the staff schedules continued to indicate the facility failed to provide evidence through timecards or payroll information that an RN was onsite for 8 consecutive hours on the following days: -5/24/25 -5/25/25 -5/31/25 -6/1/25 During an interview on 6/5/25 at 8:35 A.M., the Director of Nurses (DON) said she was not employed at the facility at the time of the PBJ Staffing report and said she would expect RN coverage to be provided as indicated per the regulation. The DON said on occasion she will come in if they need help on the weekends but said the facility does not have a staff RN always scheduled and said the facility continues to have staffing issues. During an interview on 6/5/25 at 9:37 A.M., the Administrator said the facility does not have any staffing waivers and said there should be an RN working at least 8 hours every day.

Based on interview and records reviewed, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 3 out of 3 eligible sampled CNA's. Findings include: During review of 3 CNA employee records, the Surveyor was unable to locate annual performance reviews for 3 out of 3 eligible CNA's. During an interview on 6/5/25 at 8:27 A.M., the Human Resource Director said the annual reviews were not completed and said she does not manage that process as the former Director of Nursing handled the reviews. During an interview on 6/5/25 at 1:49 P.M., the Director of Nursing (DON) said annual reviews must be completed yearly and documented in the employee record. The DON said she has not conducted any performance reviews since starting in the facility in April 2025.

Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure orientation, education and training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to: 1. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, safe, and effective resident care related to wound management, and communication with consulting providers; 2. Establish and maintain an IPCP (Infection Prevention Control Program) designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of disease and infection. 3. Implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, based on the facility assessment. 4. Develop an Antibiotic Stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. 5. Ensure that the IPCP was overseen by a qualified individual and has the appropriate knowledge and skills to care for the IPCP needs of the facility's resident population and to be responsible for the IPCP. 6. Ensure sufficient staffing according to the facility assessment and facility staffing requirements. Findings include: During the survey process it was identified that the Administration's failure to orient and educate staff on policies and procedures specifically related to residents' care and services that resulted in residents who required wound management and oversight and did not have the clinical competencies on file to provide wound assessment and wound dressing changes, resulting in the deterioration of a wound for one Resident. In addition, the facility failed to implement or maintain Enhanced Barrier Precautions and hand hygiene during a wound dressing treatment. During the survey process it was identified that the Administration's failure to implement an infection control program for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff resulted in the facility's failure to document information related to tracking and reporting of infections in the facility. The facility failed to document, monitor and report infections and document information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025. This included the failure to develop and implement an Antibiotic Stewardship Program, The facility failed to ensure an Infection Control Program was overseen by a qualified individual the has the appropriate knowledge and skills to care for the Infection Control Program needs of the facility's resident population and to be responsible for the Infection Control Program. The facility did not have a qualified Infection Preventionist working in the facility. Review of the facility staffing requirements indicated the facility was staffed below their determined minimum necessary for Licensed Nurses and CNA's and failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place. During an interview on 6/5/25 at 8:57 A.M., the Director of Nurses (DON) said training and clinical competencies must be completed upon hire and annually and said she expects staff to have been checked off as passing clinical competencies before coming off orientation. The DON said she has not completed any training or competencies with clinical staff and said she has voiced her concerns to Administration as well as the [NAME] President of Clinical Operations regarding the oversight and help needed. The DON said the facility does not have an Assistant Director of Nursing, Unit Managers or a full-time Infection Preventionist or Staff Development Coordinator at this time and said they have staff issues that need to be addressed. During an interview on 6/5/25 at 9:39 A.M., the Administrator said it is his expectation that the clinical staff are trained appropriately and have the required completed clinical competencies on file according to the facility assessment. The Administrator said he could not speak of what education had been done at the facility and did not know if any new hires had been oriented, educated, assessed for competency, or had dementia training. The Administrator said they have been without key management roles since he started in August 2024, including an Assistant Director of Nursing or a Staff Educator since last fall and said they had a staff member helping out but she is no longer here. The Administrator said the facility does not have an Infection Preventionist at this time and said he is unaware of who is managing the Infection Control Program. The Administrator said the Director of Nursing position had changed multiple times since his arrival to the building in August 2024 and said that he could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, clinical competent staffing and training/education, and quality of care or quality of life that was comprehensive and measurable with goals. The Administrator said they have been facing staffing challenges and working on hiring more staff. During an interview on 6/5/24 at 11:19 A.M., the Medical Director said he would expect that the facility implements the required training and competencies for all staff to care for the needs of the residents in the facility. During an interview on 6/05/25 at 12:36 P.M., the [NAME] President of Clinical Operations said the facility must provide the care and services that are outlined and offered per the facility assessment and said staffing has been a challenge for the facility. Despite the Nursing Home Administrator voicing knowledge that there had not been an Assistant Director of Nursing, Staff Educator, or a dedicated qualified Infection Preventionist in the building since August 2024, and that new staff hires in that time frame were not provided with orientation, or assessed for competency, the facility's administrative team failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents. Further review indicated, the facility Administration failed to make efforts to identify areas of concern, such as sufficient staffing, Infection Control Program including implementing an Antibiotic Stewardship and make attempts to improve the quality-of-care delivery.

Based on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to address sufficient staffing, education resources and include a competency-based approach, including competencies necessary upon orientation and/or annually, to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. In addition, The facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff and failed to have a qualified Infection Preventionist with completed specialized training in infection prevention and control. Findings include: Review of the Facility Assessment, dated as reviewed with the QAA/QAPI committee, in May 2025, indicated the following: Staff training/education and competencies -Considerations: Training's will be conducted based on regulation, facility need and acuity or admissions. -Infection Control: Conducted on hire, annually and retraining as needed based on CDC (Center for Disease Control) and DPH (Department of Public Health) updates for COVD-19 [SIC] and other infections. Staff Competencies: Staff Type and Timing (on hire, annually, PRN (as needed), on demand) -Person Centered Care: All staff on hire, annually and as needed. -Activities of Daily Living All staff on hire, annually and as needed. -Infection Control: Hand Hygiene, Universal Precautions, Protective Equipment. -As needed with updates from DPH, CMS (Centers for Medicaid and Medicare Services) and CDC regarding COVID-19 following all CDC guidelines. -Medication Administration: All staff on hire, annually and as needed. -Measurements - Vitals and intake and output: All staff on hire, annually and as needed. -Resident Assessment: All staff on hire, annually and as needed. -Caring for Residents with dementia, Alzheimer's, and Cognitive Impairments. 8 hours of training upon hire and 4 hours upon annual recertification. -Caring for Residents with Mental and Psychosocial Disorders: All appropriate staff upon hire, annually and as needed. -Non-Pharmacological Management of Responsive Behaviors: All staff on hire, annually and as needed. -Caring for Residents with Trauma/ PTSD (Post Traumatic Stress Disorder): All staff on hire, annually and as needed. -Clinical Competencies: All staff on hire, annually and as needed/ As COVID-19 protocols change. -Evaluation of Infection Prevention and Control Program: The facility looks at infection control through its morning clinical review. Individuals are tracked and monitored on the line listings. Line listing review identifies trends. Information is sent to the lab. This information is reviewed by the lab and processed on an infection control report which is returned to the facility. Infection control is reviewed monthly and quarterly at QAPI meetings and as needed through ad-hoc meetings if trends are identified. The infection control review includes nursing, administration, medical director and lab/X-ray provider. All staff is educated on infection control standards. The facility partners with vendors who educate and uphold infection control standards. -Staffing ratios for Nurses and Certified Nursing Aides (CNA's): -4 Licensed Practical Nurses (LPN) / Registered Nurses (RN) Full time days - weekdays and weekends. -4 LPN / RN Full time evening - weekdays and weekends. -2 LPN / RN Full time nights - weekdays and weekends. -8 CNA's Full time days - weekdays and weekends. -8 CNA's Full time evenings - weekdays and weekends. -4 CNA's Full time nights - weekdays and weekends. -Staff type/Plan: Infection Control and Prevention. 1 Full time Infection Control/ADON -weekdays and weekends if needed. During an interview on 6/5/25 at 8:52 A.M., the Director of Nurses (DON) said training and clinical competencies must be completed upon hire and annually according to the facility assessment and said she has not completed any training or competencies with clinical staff and is covering the role of infection preventionist and educator since she started. The DON said she does not have training or clinical competencies on file as required by all staff and was unable to locate any during survey. The DON said the facility needs to have a designated Infection Preventionist to monitor and implement the program and said staffing has been an issue. During an interview on 6/5/25 at 9:38 A.M., the Administrator said it is his expectation that the clinical staff are trained appropriately and have the required completed clinical competencies on file according to the facility assessment. The Administrator said he is not aware of what competencies are required and said the Staff Educator or Assistant Director manages that process and continued to say the facility does not have an Assistant Director or Staff Educator employed at this time. The Administrator said a qualified Infection Preventionist is not assigned to the building at this time and said it is the expectation that residents receive the care and services outlined in the facility assessment and that sufficient staffing needs are met.

Based on observations, and interviews, the facility failed to ensure medications were stored in locked compartments on one nursing unit. Findings include: Review of the facility policy titled, Storage of Medications, dated as revised April 2007, indicated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Only persons authorized to prepare and administer medications shall have access to the medication room, including keys. On 6/4/25 at 9:14 A.M., the surveyor observed the medication storage room was unlocked and unattended on the first floor Unit 1. The surveyor was able to open the door and gain access into the medication storage room. There were no staff present in or around the medication storage room. Residents were observed walking around the unit. On 6/4/25 at 10:08 A.M., the surveyor observed the medication storage room was unlocked and unattended on the first floor Unit 1. The surveyor was able to open the door and gain access into the medication storage room. There were no staff present in or around the medication storage room. Residents were observed walking around the unit. During an interview on 6/4/25 at 10:58 A.M., Nurse #7 said the medication storage room must be locked at all times and said she is not sure how it got unlocked. During an interview on 6/5/25 at 8:48 A.M., the Director of Nursing said medication storage rooms must always remain locked and said no one should have access to the medication rooms except the nursing staff who have the keys to unlock the doors to gain access.

2b. For Resident #9 the facility failed to ensure skin assessments were implemented in accordance with the medical plan of care. Resident #9 was admitted to the facility in August 2012 and has diagnoses that include but are not limited to metabolic encephalopathy, bipolar disorder, moderate protein malnutrition, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 scored a 7 out of 15 on the Brief Interview for Mental Stats exam which indicated he/she as having severe cognitive impairment, requires partial/moderate assistance for self-care activities including bathing and dressing. Further review of the MDS indicated Resident #9 is at risk for developing pressure ulcers/injuries. Review of Resident #9's medical record indicated a Norton Scale for Predicting Risk of Pressure Ulcers, dated 10/22/24 as high risk. Review of the physician's order dated 3/14/23 indicated: -Weekly skin assessment on TUESDAY 3-11 shift. Document on PCC (electronic medical record) under assessment. Review of Resident #9's clinical record indicated weekly skin assessments were performed on the following dates: 12/3/24, 12/17/24, 3/25/25, 4/7/25, 4/8/25, 4/22/25, 5/13/25, 5/20/25. There were no additional weekly skin checks for Resident #9. Review of the clinical record indicated from 12/1/24 through 6/3/25, Resident #9 had only 8 weekly skin assessments performed, out of 27 weeks. During an interview on 6/5/25 at 12:45 P.M., Nurse #2 said each resident should have a weekly skin check completed on an assessment in the medical record. During an interview on 6/4/25 at 1:25 P.M., the Director of Nursing (DON) said that she was aware that the facility had been having issues with nursing obtaining skin checks weekly. Based on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for six residents (#8, #68, #66, #55, #39, and #47) out of a total of 24 sampled residents. Specifically: 1. For Resident #8, the facility failed to ensure a physicians order was implemented for a newly developed skin injury. 2. For Resident #68, #66, #9, and #47 the facility failed to ensure weekly skin checks were completed as ordered. 3. For Resident #39 the facility failed to ensure pre and post skin checks were completed when donning and doffing a right wrist splint. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #8 was admitted to the facility in October 2017 with diagnoses including dementia, cognitive communication deficit, and unsteadiness on feet. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #8 is severely cognitively impaired evidenced by a score of 5 out a possible 15 on the Brief Interview for Mental Status Exam. On 6/4/25 7:11 A.M., the surveyor observed Resident #8 in bed waiting for morning care. There was a dressing on Resident #8's lower right leg initialed by staff and dated 6/3. Review of Resident #8's progress notes and physician's orders failed to indicate any injury to Resident #8's leg or treatment orders. On 6/4/25 at 7:55 A.M. the surveyor observed Resident #8 seated in the dining room wearing shorts which exposed his/her lower right leg and dressing dated 6/3. The surveyor inquired with Nurse #4 who said she was not aware of any treatment or injury to Resident #8. During an interview on 6/4/25 at 9:58 A.M., Nurse #2 said that Resident #8 had a dressing on his/her right leg but was not sure what had happened. Nurse #2 said that Resident #8 often bumps his/her legs into things. Nurse #2 said that there should be a physicians order for Resident #8's leg. Nurse #2 reviewed Resident #8's physicians orders and said that there was no order for treatment. During an interview on 6/4/25 at 1:26 P.M., the Director of Nursing (DON) said that when a resident sustains a skin injury, the expectation is for an investigation and skin assessment to be completed, the physician to be alerted and for treatment orders to be obtained. The DON said she had been made aware today (6/4/25) that Resident #8 had a dressing placed on a skin injury without an order. 2a. Resident #68 was admitted to the facility in September 2024 with diagnoses including vascular dementia, hemiplegia, and anxiety disorder and depressive disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #68 is moderately cognitively impaired evidenced by a score of 10 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #68's physicians orders indicated two orders for weekly skin checks: Weekly skin assessment to be completed Thursday on the 7am-3pm shift. Document Findings under the assessment tab NSG: Skin Assessment, dated 4/24/25. Weekly skin check on Thursday 3-11 shift, dated 9/27/24. Review of Resident #68's clinical record indicated skin checks were performed on the following dates: 1/2/25, 3/15/25, 4/28/25, 5/1/25, 5/8/25 and 5/22/25. Review of Resident #68's care plans indicated: Resident has a potential for pressure ulcer development r/t (related to) immobility, left sided There were no additional skin checks completed for Resident #68. During an interview on 6/4/25 at 1:25 P.M., the Director of Nursing (DON) said that she was aware that the facility had been having issues with nursing obtaining skin checks weekly. 2b. Resident #66 was admitted to the facility in September 2024 with diagnoses including Alzheimer's disease. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #66 is severely cognitively impaired evidenced by a score of 00 out of a possible 15 on the Brief Interview for Mental Status exam. Review of Resident #66's physicians orders indicated two orders related to skin checks: Weekly skin check, dated 9/25/24. Weekly skin assessment to be completed Monday on the 3pm-11pm shift. Document Findings on under the assessment tab NSG: Skin Assessment, dated 4/28/25 Review of the clinical record indicated skin checks for Resident #66 were completed on; 12/25/24, 1/1/25, 25, 3/25/25, 4/23/35, 4/30/25 and 5/7/25. No other skin checks completed. During an interview on 6/4/25 at 1:25 P.M., the Director of Nursing (DON) said that she was aware that the facility had been having issues with nursing obtaining skin checks weekly. 2c. Resident #30 was admitted to the facility in October 2020 with diagnoses that included dementia, type 2 diabetes and muscle weakness. Review of Resident #30's most recent Quarterly Minimum Data Set (MDS) Assessment, dated, 3/21/25, indicated a Brief Interview for Mental Status score of 10 out of 15 indicating moderate cognitive impairment. The MDS further indicated that the Resident requires partial to moderate assistance for bed mobility and had not exhibited rejection of care. The MDS also indicated that the Resident is at risk for pressure ulcer development. Review of Resident #30's active physician's orders indicated: -Weekly skin assessment to be completed Tuesday on the 7am-3pm shift. Document Findings on [Electronic Medical Record (EMR)] under the assessment tab NSG: Skin Assessment., dated 4/28/25. Review of Resident #30's discontinued physician's orders indicated: -Weekly skin assessment on TUESDAYS 7-3 shift. Document on [EMR] under assessment., in place from 3/21/23 through 4/28/25. Review of the most recent Norton Assessment (an assessment to determine risk for pressure ulcer development), dated 2/19/25, indicated a risk score of 7, which indicates high risk for skin breakdown. Review of Resident #30's active skin care plan, dated as revised 9/28/23, indicated Skin: [Resident] is at risk for skin breakdown as evidenced by: Shear/friction risks. Review of the Electronic Medical Record indicated that the NSG: Skin Assessment was completed on the following dates over the last six months: 12/3/24, 12/12/24, 12/20/24, 2/21/25, 4/29/25, 5/8/25, 5/16/25 and 6/3/25. Review of progress notes from 12/1/24 through 6/3/25 failed to indicate any skin checks were completed that were not documented in a Skin Assessment and failed to indicate that the Resident had refused a skin assessment or skin check. During an interview on 6/4/25 at 12:37 P.M., Nurse #5 said that until recently there has not been a regular Director of Nurses at the facility to oversee that skin checks are being completed. She said that the expectation is that physician's orders are followed to complete skin checks weekly. She said that completing the skin check includes opening the assessment and entering whether the resident has any skin concerns or not. Nurse #5 said that not assessing a resident's skin weekly could lead to new wounds forming that are not known about that could worsen or become infected. During an interview on 6/4/25 1:25 P.M., The Director of Nurses said that she would expect that skin checks are completed weekly based on physician's orders, including completing the Skin Assessment in the EMR. 2d. Resident #47 was admitted to the facility in August 2020 with diagnoses including diabetes, anxiety, and depression. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #47 is moderately cognitively impaired evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #47's physicians orders, dated 5/4/25, indicated: Weekly skin assessment to be completed Sunday on 7am-3pm shift. Document findings in electronic medical record under skin assessment tab. Review of Resident #47's clinical record indicated skin checks were performed on the following dates: 1/19/25, 4/7/25, and 5/11/25. There was no additional skin checks completed for Resident #47. During an interview on 6/4/25 at 1:25 P.M., the Director of Nursing (DON) said that she was aware that the facility had been having issues with nursing obtaining skin checks weekly. 3. Resident #39 was admitted to the facility in May 2020 with diagnoses including Diabetes and Congestive Heart Failure. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #39 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #39's physicians orders, dated 4/28/25, indicated: [NAME] right wrist brace in morning, doff at night related to right hand osteoarthritis and gout per orthopedic recommendations. Complete as tolerated and complete skin check pre and post wear. Review of Resident #39's clinical record failed to indicate any documentation of skin checks pre and post wear of right wrist brace. Review of Resident #39's weekly skin checks, dated 5/8/25, 5/16/25, and 5/29/25 failed to indicate any reference to skin under right wrist brace. During an interview 6/4/25 at 7:31 A.M., Resident #39 said he can remove and replace the splint independently. He said that nursing does not check the skin under his/her splint. During an interview on 6/4/25 at 10:01 A.M., Nurse #5 said that nurses need to do skin check before and after use of splint, even if resident dons and doffs independently. During an interview on 6/4/25 at 1:25 P.M., the Director of Nursing (DON) said that she was aware that the facility had been having issues with nursing obtaining skin checks weekly.

3. For Resident #60 the facility failed to ensure accuracy of the MDS related to documentation from the physician that a gradual dose reduction of administered antipsychotic medication was documented as clinically contraindicated. Resident #60 was admitted to the facility in November 2023 and has diagnoses that include but are not limited to unspecified dementia, encephalopathy, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a staff assessment of mental status indicated Resident #60 as having severe cognitive impairment, and he/she is dependent on staff for self-care including toileting, bathing and dressing. Review of the MDS dated [DATE] indicated under Section N, High-Risk Drug classes that Resident #60 is taking antipsychotic medication, the physician documented a GDR (gradual dose reduction) as clinically contraindicated. The physician documented the GDR as clinically contraindicated in a note dated 12/3/24. Review of the Nurse Practitioner note dated 12/3/24 failed to indicate that a GDR of the antipsychotic medication as clinically contraindicated. The MDS dated [DATE] under section N, High-Risk Drug classes indicated Resident #60 is taking antipsychotic medication, the physician documented a GDR (gradual dose reduction) as clinically contraindicated. The physician documented the GDR as clinically contraindicated in a note on 3/4/2025. Review of the Nurse Practitioner note dated 3/4/25 failed to indicate that a GDR of the antipsychotic medication as clinically contraindicated. During an interview on 6/3/25 at 3:03 P.M., the MDS Nurse said when she does the MDS, the date she uses to support documentation for a GDR to be clinically contraindicated is documented by the psychiatric nurse practitioner who reviews residents for psychotropic medications use. Review of the notes with the MDS nurse, written and dated 12/3/24 and 3/4/25 by the psychiatric nurse practitioner, failed to indicate a GDR was clinically contraindicated. The MDS nurse said those notes should not have been used to complete the MDS, and she would need to modify the MDS to be accurate. Based on record review and interview, the facility failed to ensure Minimum Data Set Assessments (MDS') to be coded accurately for three Residents (#68, #21, #60) out of a total of 24 sampled residents. Findings include: 1. Resident #68 was admitted to the facility in September 2024 with diagnoses including vascular dementia, hemiplegia, and anxiety disorder and depressive disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #68 is moderately cognitively impaired evidenced by a score of 10 out of a possible 15 on the Brief Interview for Mental Status Exam. Additional review of the MDS' dated 4/4/25, 1/2/25 and 10/3/24 failed to indicate Resident #68's diagnoses of anxiety and depression were coded on the MDS. During an interview on 6/4/25 at 11:42 A.M., the MDS Nurse said that MDS' should be coded accurately. The MDS nurse said that she was not aware of Resident #68's diagnoses. 2. Resident #21 was admitted to facility in October 2018 with diagnoses including stroke, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #21 is severely cognitively impaired and totally dependent on staff for all activities of daily living. Additional review of the MDS indicated Resident #21 has two pressure injuries that were present upon admission. Review of the clinical record indicated Resident #21 developed pressure injuries to his/her sacrum and hip while residing at the facility. During an interview on 6/4/25 at 11:42 A.M., the MDS Nurse said that MDS' should be coded accurately. The MDS Nurse said that Resident #21's MDS was coded inaccurately.

Based on observations, interviews and record review, the facility failed to report an allegation of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to report allegations of physical abuse, sexual abuse and mental abuse to the (SA) state agency. Findings include: A review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: Identification: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Action: -Immediately protect Resident from alleged abuse. -Immediately notify your administrative staff or nursing supervisor on duty of abuse allegation. -The Administrative staff/Nursing supervisor will immediately report all allegations to the Administrator and Director of Nurses. -Immediately suspend employee pending investigation. -The facility will notify the Department of Public Health and Local law enforcement no later than two hours after abuse allegation was received. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During an interview on 6/13/24 at 7:21 A.M., the Unit manager said all allegations of abuse reported by residents should be reported to the state agency and law enforcement within two hours. During an interview on 6/11/24 at 1:11 P.M., the Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours. A review of the Health Care Facility reporting system (HCFRS) did not indicate any abuse allegations were reported in May 2024 and prior to June 10, 2024.

Based on observations, interviews and record review, the facility failed to investigate allegations of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to investigate allegations of physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: -Any complaint of, or suspicion of resident abuse shall be thoroughly investigated. -Facility investigation will be completed within 72 hours of the incident, documentation of investigation to be completed by initiating an incident and accident report, obtaining statements from identified potential witnesses, completing necessary evaluations (i.e. skin/body checks, pain evaluation), and maintaining a timeline of events. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA #1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During an interview on 6/13/24 at 7:21 A.M., the Unit manager said she manages all the units in the facility. She said she was a part of an abuse/neglect in-service on 5/29/24 presented by the ADON. She said she was not aware of the details but was aware abuse allegations had been made by a resident on the first floor. She said all allegations of abuse made by residents should be investigated. During an interview on 6/11/24 at 1:11 P.M., the Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events.

Based on observations, interviews and record review, the facility failed to implement their abuse policy for one Resident (#41) out of a sample of 24 residents. Specifically, 1. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) failed to notify the Administrator about allegations of physical, sexual and mental abuse, 2. Keep Resident #41 safe by suspending the staff member involved in the abuse allegations, 3. Failed to report and investigate the abuse allegations as required, and 4. Failed to report the allegations to the state agency (SA) and law enforcement. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: Identification: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Action: -Immediately protect Resident from alleged abuse. -Immediately notify your administrative staff or nursing supervisor on duty of abuse allegation. -The Administrative staff/Nursing supervisor will immediately report all allegations to the Administrator and Director of Nurses. -Immediately suspend employee pending investigation. -The facility will notify the Department of Public Health and Local law enforcement no later than two hours after abuse allegation was received. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurt as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the DON about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the ADON said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said their parent told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago. They said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their parent, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their parent's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During a telephone interview on 6/14/24 at 10:10 A.M., CNA #1 said he has never provided care to Resident #41 because he/she is able to provide his/her own Activities of Daily Living. CNA #1 said Resident #41 is able to shower/bathe and transfer himself/herself. A review of Resident #41's May 2024 Shower/Bathe self-tasks signed off by CNA #1 indicated the following: -Partial/Moderate Assistance, helper does less than half of the effort, helper lifts, holds or supports trunk or limbs but provides less than half of the effort. -Supervision/Touching Assistance, helper provided verbal cues and or touching, steadying or contact guard assistance. Assistance may be provided throughout or intermittently. -Evening Shift: -5/18-Supervision/Touching assistance, 5/20-Supervision/Touching assistance, 5/21-Partial/Moderate assistance, 5/24-Partial/Moderate assistance. -Night Shift: -5/4-Partial/Moderate assistance,5/6-Partial/Moderate assistance,5/7-Partial/Moderate assistance, 5/13-Partial/Moderate assistance, 5/21-Partial/Moderate assistance, 5/23-Partial/Moderate assistance, 5/28-Partial/Moderate assistance. A review of Resident #41's June 2024 Sit to Lying tasks signed off by CNA #1 indicated the following: Evening Shift: -6/1-Supervision/Touching assistance, 6/3-Supervision/Touching assistance, 6/4-Supervision/Touching assistance, 6/7-Supervision/Touching assistance. -Night Shift: 6/2-Supervision/Touching assistance, 6/5-Partial/Moderate assistance, 6/8-Supervision/Touching Assistance. During an interview on 6/13/24 at 7:21 A.M., the Unit Manager said all abuse allegations made by residents should be reported to the ADON, DON and Administrator. During an interview on 6/11/24 at 1:11 P.M., the Administrator said he was not aware of any concerns reported by the Resident. He said he expects to be made aware of any abuse allegations made by residents. The ADON and DON said they managed the concerns as customer service with the family members, so they did not report them to the Administrator. The DON and ADON said the facility expectation is, all allegations of abuse should be reported to the Administrator so an investigation can be initiated. The Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events. The Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours.

Based on observations, interviews and record review, the facility failed to provide a safe environment free from abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to provide an environment free from physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON then said the facility has also provided education to staff, including CNA #1. The ADON said the only new concern that she was not aware of was the pain the Resident was reporting on his/her shoulder. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] The ADON provided an inservice she instructed, dated 5/29/24, signed off by staff. The list of staff did not include CNA #1. Review of the 5/29/24 staff schedule indicated CNA#1 called out. The inservice's subject was Resident #41. The detailed instruction of the inservice indicated the following: -When giving Resident showers, do not touch Resident, just give Resident face cloths and allow Resident to wash himself/herself. -When helping Resident at midnight, please do not yell, talk in low voice before assisting Resident. During an observation and interview on 6/12/24 at 8:00 A.M., Resident #41 was observed sitting on his/her bed, he/she did not give any eye contact to the surveyor, he/she looked down during the whole interview. Resident #41 said he/she was in so much pain this morning, he/she rated his/her pain at an 8 out of a possible 10. The Resident said his/her body is already in pain from his/her neuropathy and cancer diagnosis. He/she said since CNA #1 threw him/her on the bed, his/her pain level has increased on his/her shoulder, he/she said he/she is in pain when he/she breathes in and out. The Resident said when CNA #1 was in the shower with him/her, he/she felt violated by him, especially after he/she offered to clean himself/herself, the CNA refused and then proceeded to forcefully spread his/her legs and began scrubbing between his/her legs, turning him/her around to reach between his/her legs. The Resident said he/she felt as if he/she was getting a private parts wash. The Resident said he/she has never been touched by a staff member in that way, he/she felt his/her boundaries were violated, he/she said both incidents keep replaying in his/her head. Resident #41 said no one in the facility has sat down to talk to him/her about the incidents. Resident #41 said he/she would like to speak to a therapist to work through both incidents with a professional. During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping him/her take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside, and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. A review of Resident #41's May 2024 Shower/Bathe self-tasks signed off by CNA #1 indicated the following: -Partial/Moderate Assistance, helper does less than half of the effort, helper lifts, holds or supports trunk or limbs but provides less than half of the effort. -Supervision/Touching Assistance, helper provided verbal cues and or touching, steadying or contact guard assistance. Assistance may be provided throughout or intermittently. -Evening Shift: -5/18-Supervision/Touching assistance, 5/20-Supervision/Touching assistance, 5/21-Partial/Moderate assistance, 5/24-Partial/Moderate assistance. -Night Shift: -5/4-Partial/Moderate assistance,5/6-Partial/Moderate assistance,5/7-Partial/Moderate assistance, 5/13-Partial/Moderate assistance, 5/21-Partial/Moderate assistance, 5/23-Partial/Moderate assistance, 5/28-Partial/Moderate assistance. A review of Resident #41's June 2024 Sit to Lying tasks signed off by CNA #1 indicated the following: Evening Shift: -6/1-Supervision/Touching assistance, 6/3-Supervision/Touching assistance, 6/4-Supervision/Touching assistance, 6/7-Supervision/Touching assistance. -Night Shift: 6/2-Supervision/Touching assistance, 6/5-Partial/Moderate assistance, 6/8-Supervision/Touching Assistance. During a telephone interview on 6/14/24 at 10:10 A.M., CNA #1 said he has never provided care to Resident #41 because he/she is able to provide his/her own Activities of Daily Living. CNA #1 said Resident #41 is able to shower/bathe and transfer himself/herself. During an interview on 6/11/24 at 1:11 P.M., the Administrator said he was not aware of any concerns reported by the Resident. He said he expects to be made aware of any abuse allegations made by residents. The ADON and DON said they managed the concerns as customer service with the family members so they did not report them to the Administrator. The DON and ADON said the facility expectation is, all allegations of abuse should be reported to the Administrator so an investigation can be initiated. The Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events. The Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours.

Based on observation, record review and interview, the facility failed to prevent a decrease in range of motion for 1 Resident (#17) resulting in a hand contracture, out of a total sample of 25 residents. Findings include: Resident #17 was admitted to the facility in June 2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to be severely cognitively impaired. Further review of section G of the MDS indicated Resident #19 did not have impairment in range of motion. On 2/8/22 at 10:43 A.M., Resident #17 was observed sitting in a reclining chair in the hallway. His/her left hand was in a closed position making a fist. Review of Resident #17's nursing notes and skilled nursing assessments did not indicate that his/her [CONDITION(S)] or decreased in range of motion on his/her left hand was a result of either dementia or [CONDITION(S)]. Review of the Occupational Therapy evaluation dated 3/30/21 failed to indicte Resident #17 had an impairment in range of motion of his/her left hand. On 2/09/22 at 10:20 A.M., Certified Nursing Assistant (CNA) #1 said that she was unaware if Resident #17 could fully open his/her left hand. At this time, CNA #1 attempted to fully open Resident #17's left hand. Resident #17 was able to straighten his/her thumb and pointer finger, however, could not straighten his/her middle, ring or pinky fingers. As CNA #1 attempted to open these three fingers, Resident #17 began to grimace and scream, and CNA #1 stopped. Once at rest, Resident #17 no longer was screaming or grimacing. CNA #1 said that Resident #17 did not appear to be resisting but that the three fingers were stuck. During an interview on 2/09/22 at 11:45 A.M., the Assistant Director of Nursing Services said that she expects range of motion to be completed for all residents as needed. During an interview on 2/09/22 at 12:14 P.M., the Director of Rehabilitation (DOR) said that she completes rounds throughout the entire facility daily and looks for any change of function, including a change in a resident's range of motion. The DOR observed Resident #17's left hand with the surveyor and said that this was a new change in his/her's range of motion and that the last time he/she received therapy services he/she was able to fully open his/her left hand and straighten all fingers. The DOR said that she had not been made aware of this change by nursing staff but, due to Resident #17 being on hospice services, nursing would not have referred him/her to therapy. The DOR said that residents who are on hospice services are not typically treated by therapy. During an interview on 2/09/22 at 12:21 P.M., Nurse #2 said she was unaware of Resident #17's decline in range of motion and was unsure of when the decline occurred. During an interview on 2/09/22 at 12:48 P.M., Resident #17's Physician said that she was unaware of his/her decrease in range of motion and that she would have wanted to be informed of this so that a treatment plan could have been developed. The Physician said that contractures may occur because of dementia and that they are preventable if a resident is given a device to hold in their hand. The Physician then observed Resident #17's left hand and said that it was definitely tight and that the nails on the closed fingers were digging into the skin of Resident #17's palm. The Physician said that even though Resident #17 is on hospice, she would like the hand to be treated because a contracture can cause pain and skin integrity issues.