Every finding on record at Masconomet Rehabilitation and Healthcare Center

Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety, potentially putting the residents at risk for foodborne illness. Specifically, the facility failed to:1. Ensure that food was stored, labeled, and dated properly, and that food/beverages were not expired; and2. Ensure staff did not handle ready-to-eat food with contaminated gloves. Findings include:1. Review of the facility's policy titled, Food Receiving and Storage, dated November 2022, indicated but was not limited to the following:-All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).-Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded.-Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto these foods.-Foods and snacks kept on nursing units: beverages are dated when opened and discarded after twenty-four (24) hours. Review of the facility's policy titled, Food Preparation and Service, dated November 2022, indicated but was not limited to the following:- Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese.-Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods.-Appropriate measures are used to prevent cross-contamination. These include: storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator. During a walk through in the main kitchen walk-in refrigerator on 3/10/26 at 7:39 A.M., the following was observed:-Two bins of onions stored on the bottom shelf, both of which contained multiple yellow onions covered with a green and white substance resembling mold.-A case of raw bacon stored on the middle shelf above a case of milk.-An opened blue bag of hard-boiled eggs, loosely secured by a piece of plastic wrap, directly exposed to air. -Eight loaves of baked sweet bread on a sheet pan, undated and directly exposed to air. During a walk through in the main kitchen dry storage area on 3/10/26 at 7:51 A.M., the following was observed:-A case of nectar-thick tea packets with a use by date of 10/23/25. During an observation on 3/10/26 at 8:05 A.M., the reach-in refrigerator contained the following food items:-A container of egg salad, halfway full, dated 3/2/26.-A container of chicken salad, halfway full, dated 3/7/26. During an observation on 3/11/26 at 8:23 A.M., the first-floor nourishment kitchen refrigerator contained the following:-A carton of Lactaid milk, opened and halfway full, with a best by date of 1/26/26 and no opened date. -A bottle of Thick and Easy nectar-thick apple juice, opened and halfway full, with a best by date of 1/22/26 and no opened date. During an interview on 3/11/26 at 7:50 A.M., the Food Service Director (FSD) said all food/beverage items should be marked with a received date and opened date. The FSD said staff inspect and rotate foods in the main kitchen at least twice weekly; she would expect moldy or rotten food items to be discarded immediately and would also notify the vendor. The FSD said raw bacon should not be stored over milk and all foods should be covered due to cross-contamination risks. In addition, the FSD said the facility policy is to discard opened/prepared foods after two days, and that the egg salad and chicken salad in the reach-in refrigerator should have already been discarded. The FSD said that residents are at increased risk of foodborne illness if food/beverages are not stored, dated, or labeled properly. During a follow-up interview on 3/11/26 at 8:51 A.M., the FSD said dietary staff are responsible for checking the nourishment kitchens at least twice daily at 5:30 A.M., and 2:30 P.M., which would include discarding any items past their best by, use by, or expiration dates. The FSD said nursing staff are responsible for dating any opened beverages in the nourishment kitchens and she has provided education to nursing staff about dating/labeling. 2. Review of the facility's policy titled, Food Preparation and Service, dated November 2022, indicated the following:-Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.-Gloves are worn when handling food directly and changed between tasks. On 3/10/26 at 7:59 A.M., the surveyor observed the breakfast line in the main kitchen and made the following observation:-The cook touched the oven handle with gloved hands, potentially contaminating his gloves, removed a whole quiche by flipping it from the aluminum pan into his gloved hands, held the quiche to slice it into pieces, and placed the pieces of quiche onto resident plates. With the same contaminated gloves, the cook then proceeded to directly handle multiple pieces of ready-to-eat toast while placing them on resident plates. On 3/11/26 at 7:46 A.M., the surveyor and the FSD observed the breakfast line in the main kitchen and made the following observation:-The cook grabbed shelled eggs from a carton with gloved hands, cracked the eggs directly into a pan on the stove, touched the handle of the pan to move the eggs, and then touched the handle of the steamer to retrieve a pan of ready-to-eat pancakes, potentially contaminating his gloves. With the same contaminated gloves, the cook then proceeded to directly handle multiple pancakes while placing them on resident plates. During an interview on 3/11/26 at 7:50 A.M., the FSD said her expectation is that dietary staff should use a utensil or glove when touching ready-to-eat food, and should change gloves when they are contaminated, such as after touching equipment handles or raw eggs. The FSD said she does not do regular food handling education with her staff.

Based on observations, record review, and interviews, for one Resident (#77), out of 26 sampled residents, the facility failed to provide an environment free of accidents and hazards to prevent injury. Specifically, for Resident #77, who has a history of repeated falls, the facility failed to ensure fall mats were in place as ordered by the physician. Findings include:Review of the facility's policy titled Falls and Fall Risk, Managing, dated as revised March 2018, indicated:Resident-Centered Approaches to Managing Falls and Fall Risk.1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Resident #77 was admitted to the facility in November 2024 and has diagnoses that include dementia, anxiety disorder, and repeated falls. Review of Resident #77's most recent Minimum Data Set (MDS) assessment, dated 2/12/26, indicated on the Brief Interview for Mental Status exam Resident #77 scored 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #77 was dependent on staff for Activities of Daily Living (ADL). Review of Resident #77's active Physician's Orders indicated the following order: Safety floor mats next to bed while patient is in bed, check placement every shift, start date 4/1/25. Review of Resident #77's Functional Ability Assessment, dated 2/12/26, indicated that Resident #77 was dependent on staff for ADLs. Review of Resident #77's Falls Care Plan indicated I am at risk for falls r/t (related to) Impaired balance and mobility, poor safety awareness, use of psychotropic medications, visual impairment, dated as revised 12/1/25. Interventions include:-Fall Mats placed to Bilateral sides of bed, start date 2/17/26. Resident #77's care plan failed to indicate refusal or removal of the fall mat(s). Review of Resident #77's falls Kardex (resident specific care instructions and needs) indicated the following interventions:-Fall Mats at bedside. Review of Resident #77's March 2026 clinical progress notes failed to indicate refusal or removal of the fall mat(s). Review of Resident #77's accident and incident report provided by the facility indicated that Resident #77 sustained an unwitnessed fall in his/her room on 2/17/26. According to the investigation, Resident #77 was found on the fall mat beside his/her bed. On 3/10/26 at 9:04 A.M. and 10:07 A.M., the surveyor observed Resident #77 in bed. The fall mats were not in place beside the bed but rather leaning against a wall. On 3/11/26 at 8:35 A.M. and 10:23 A.M., the surveyor observed Resident #77 in bed. There was a fall mat on right side of bed, but the left side fall mat was observed folded up and leaning against a wall. During an interview on 3/12/26 at 8:29 A.M., Certified Nursing Assistant (CNA) #1 said Resident #77 requires total assist with ADLs. CNA #1 said that Resident #77 is easily redirected if he/she has behaviors and does not move the fall mat. CNA #1 said that whenever Resident #77 is in bed, the fall mats should be in place. She said that if the mats are moved while care is provided, staff are expected to put them back in place afterward. During an interview on 3/12/26 at 8:32 A.M., Nurse #5 said that Resident #77 requires total care. Nurse #5 said that Resident #77's fall mats should be in place whenever he/she is in bed. Nurse #5 said that if the staff move the mats when providing care or feeding the Resident the mats should be put back in place when the care is complete. During an interview on 3/12/26 at 8:53 A.M., the Director of Nursing said that the fall mats should be in place whenever Resident #77 is in bed.

Based on observations, record review, and interview, the facility failed to ensure one Resident's (#91) hand roll was in place as ordered by the physician, out of a total sample of 26 residents. Findings include:Review of the policy titled Resident Mobility and Range of Motion, dated as revised July 2017, indicated:2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion). 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and will be consistent with state laws and practice acts. 8. Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. Resident #91 was admitted to the facility in November 2024 and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left dominant side. Review of Resident #91's most recent Minimum Data Set (MDS) assessment, dated 12/30/25, indicated that on the Brief Interview for Mental Status exam Resident #91 scored 10 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #91 had functional limitations in range of motion on both upper extremities and was dependent on staff for Activities of Daily Living (ADLs). Review of Resident #91's active Physician's Orders indicated:-Hand roll to left hand at all times, may remove for ADLs. Inspect skin every shift, start date 4/1/25. Review of Resident #91's active care plans indicated:-An ADL care plan, dated as revised 5/16/25, indicating Resident #91 is dependent on staff for all ADLs. -A chronic pain care plan that includes the following intervention: Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, start date 6/4/25. Further review of Resident #91's care plans failed to indicate the hand roll as an intervention, including the refusal of the hand roll or removal of the hand roll by Resident #91. Review of an outpatient therapy note, dated 6/23/25, indicated Resident #91 was seen due to severe contracture to his/her LUE (left upper extremity) and RLE (right lower extremity). Review of the most recent Nursing Quarterly Assessment, dated 12/25/25, indicated that Resident #91 experienced pain during movement and care due to the presence of contractures. During an observation and interview on 3/10/26 at 8:48 A.M., the surveyor observed Resident #91 in bed. The surveyor observed Resident #91's left hand to be contracted and there was no hand roll in place or observed in the vicinity. Resident #91 said he/she is supposed to wear a brace on his/her left hand/arm at night but that they didn't put it on last night because he/she didn't ask for it. On 3/11/26 at 7:22 A.M., the surveyor observed Resident #91 in bed asleep. There was no hand roll in place. During an observation and interview on 3/11/26 at 8:50 A.M., the surveyor observed Resident #91 in bed, with no hand roll in place. Resident #91 said that his/her hand hurts when the staff put in the hand roll, but that once it is in it feels good. Resident #91 said that he/she often forgets to ask staff to put the hand roll in and that they do not put it in unless he/she asks. On 3/11/26 at 10:22 A.M., the surveyor observed Resident #91 in bed asleep. There was no hand roll in place. On 3/12/26 at 7:37 A.M., the surveyor observed Resident #91 in bed asleep. There was no hand roll in place. During an interview on 3/12/26 at 8:40 A.M., Certified Nursing Assistant (CNA) #2 said that Resident #91 is dependent for ADL care. CNA #2 said that she was not aware that Resident #91 has an order for a hand roll but that is something that the nurse would be responsible for. During an interview on 3/12/26 at 8:42 A.M., Nurse #5 said that Resident #91 is supposed to have the hand roll in at all times except when staff provide care. He said that despite Resident #91's pain, if you are gentle, you are able to slowly get the roll in place. Nurse #5 said that Resident #91 does not refuse the hand roll and if he/she did the nurses would write a note. During an interview on 3/12/26 at 8:53 A.M., the Director of Nursing said that Resident #91's hand roll should be in place, and it is the expectation that the nurses document if refused.

Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for two Residents (#67 and #112), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #67, to ensure Oxygen was administered in accordance with the physician's order; and 2. For Resident #112, to ensure Oxygen was administered according to the physician's orders, nebulizer (a medical device that converts liquid medication into a fine, breathable mist for direct inhalation into the lungs through a mask or mouthpiece) tubing was dated, and a nebulizer mask was stored appropriately. Findings include: Review of the facility's policy titled Oxygen Administration, dated 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. -Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 1. Resident #67 was admitted to the facility in February 2026 with diagnoses including idiopathic pulmonary fibrosis (a chronic, progressive lung disease characterized by scarring of lung tissue), pneumonia, and acute respiratory failure with hypoxia (low oxygen levels). Review of Resident #67's most recent Minimum Data Set (MDS) assessment, dated 2/11/26, indicated that Resident #67 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15. The MDS further indicated that the Resident received continuous oxygen therapy and required assistance from staff for activities of daily living. During an observation with interview on 3/10/26 at 10:16 A.M., the surveyor observed Resident #67 sitting in a wheelchair wearing an oxygen nasal canula (a flexible tube with two small prongs inserted into the nostrils to deliver supplemental Oxygen). The oxygen concentrator was set to 3 liters per minute. The Resident said his/her baseline setting is 2 liters per minute. On 3/11/26 at 7:04 A.M., the surveyor observed Resident #67 lying in bed wearing an oxygen nasal cannula. The oxygen concentrator was set to 3 liters per minute. On 3/11/26 at 8:48 A.M., the surveyor observed Resident #67 lying in bed wearing an oxygen nasal cannula. The oxygen concentrator was set to 3 liters per minute. During an observation with interview on 3/11/26 at 11:00 A.M., the surveyor observed Resident #67 sitting in a wheelchair wearing an oxygen nasal cannula. The oxygen concentrator was set to 2.5 liters per minute. The Resident said his/her oxygen was set to 3 liters per minute earlier that day, but he/she thought the setting was too high, so staff decreased it to 2.5 liters per minute. Review of Resident #67's active Physician's Orders indicated: Oxygen continuous via nasal cannula at 2 liters per minute, every shift continuous (14 hours or greater per day continuous), start date 2/9/26. Review of Resident #67's Respiratory Care Plan, last revised 2/24/26, indicated the following intervention: Oxygen a/o (as ordered). Review of Resident #67's most recent laboratory results, dated 3/3/26, indicated an elevated carbon dioxide level of 35 milliequivalents per liter (normal range: 22-29 milliequivalents per liter). During an interview on 3/11/26 at 11:03 A.M., Nurse #4 said Oxygen orders should be followed as prescribed by the physician. Nurse #4 said Resident #67 has not had any change in respiratory status or increased difficulty breathing that would necessitate an oxygen concentrator setting above the ordered 2 liters per minute. Nurse #4 said a resident with a diagnosis of acute respiratory failure with hypoxia should not have oxygen levels more than ordered secondary to the risk of carbon dioxide retention. During an interview on 3/11/26 at 1:29 P.M., the Director of Nursing (DON) said Oxygen orders should be followed as prescribed by the physician and that a resident with a diagnosis of acute respiratory failure with hypoxia should not have oxygen levels more than ordered secondary to the risk of carbon dioxide retention. The DON said she would expect Resident #67's oxygen concentrator to be set at 2 liters per minute in accordance with the physician's order. 2. Resident #112 was admitted to the facility in February 2026 with diagnoses including chronic respiratory failure with hypoxia. Review of Resident #112's most recent MDS assessment, dated 3/3/26, indicated the Resident scored 15 out of 15 on the BIMS exam indicating he/she was cognitively intact. The MDS further indicated that the Resident was on oxygen therapy. On 3/10/26 at 10:49 A.M., the surveyor observed Resident #112 wearing an oxygen nasal cannula, the oxygen concentrator was set to 3 liters. The Resident said he/she should be on 2 liters of Oxygen. The Resident further said he/she does not adjust the settings of the Oxygen. A nebulizer machine was noted on top of the Resident's drawer, the tubing was undated, and the mask was next to a plastic food container, a glass vase, and a box of gloves. On 3/11/26 at 7:07 A.M., the surveyor observed Resident #112 wearing an oxygen nasal cannula, the oxygen concentrator was set to 3 liters. A nebulizer machine was noted on top of the Resident's drawer, the tubing was undated, and the mask was next to a plastic food container, a glass vase, and a box of gloves. On 3/11/26 at 10:38 A.M., the surveyor observed Resident #112 wearing an oxygen nasal cannula, the oxygen concentrator was set to 3 liters. The Resident was also inhaling medication via the nebulizer mask. The surveyor asked Nurse #2 who was standing at the doorway to the Resident's room to look at the oxygen setting. Nurse #2 removed the Resident's nebulizer mask and confirmed the oxygen concentrator was set to 3 liters. The Nurse then placed the nebulizer mask on top of the Resident's drawer. Review of the current Physician's Orders indicated the following: -Date 3/4/26: Oxygen PRN (as needed) via (N/C) at (2) Liters Per Minute- to keep O2 sats above 90% as needed for if O2 sats are under 90% apply O2. [sic] -Date 3/4/26: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally via nebulizer two times a day for Respiratory Treatments & compliance until 3/14/26 11:26 Supplementary Documentation Codes Pre and Post Tx Lung Sounds C = ClearO = Other (see progress note) Pre and Post Tx - P, R and O2 Sat results MNS - Enter the number of minutes of nurse time for the medication administration.[sic] -Date 2/24/26: Respiratory Bag Change: Change and date bag every night shifts every Thu. [sic] Review of the Resident's Oxygen Therapy Care Plan, date initiated 2/25/26, indicated the Resident has Oxygen with an intervention of Oxygen as ordered. During an interview on 3/11/26 at 10:40 A.M., Nurse #2 said the Resident should be on Oxygen at 2 Liters per minute and that the nebulizer tubing should be dated weekly and the mask stored in a respiratory bag for infection control. During an interview on 3/11/26 at 10:46 A.M., Unit Manager #1 said Oxygen should be administered as ordered, nebulizer tubing is changed weekly, and masks are stored in the respiratory plastic bags. During an interview on 3/11/26 at 1:30 P.M., the DON said Oxygen should be administered at the ordered setting, nebulizer tubing is changed weekly and dated, and nebulizer masks should be stored in the respiratory bag. She further said when Oxygen is administered at the wrong setting it could lead to the Resident retaining carbon dioxide which could be dangerous.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed. Findings include:Review of the facility's policy titled 'Medication Labeling and Storage', revised February 2023, indicated:-Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.-Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration. On 3/11/26 at 6:55 A.M., the surveyor and Nurse #1 observed the following in the Gould unit medication cart:-One Fluticasone Furoate inhaler, opened and undated.-Spiriva Handihaler inhaler, opened and undated.-Ipratropium Bromide nasal solution, opened and undated.-Liquid protein supplement, opened and undated. During an interview on 3/11/26 at 7:05 A.M., Nurse #1 said the medications should have been dated when they were opened. During an interview on 3/11/26 at 7:15 A.M., Unit Manager #1 said medications should have been dated when they were opened. During an interview on 3/11/26 at 1:34 P.M., the Director of Nursing said the medications with shortened expiration should be dated when opened.

Based on observation, record review, and interviews, the facility failed to ensure transmission-based precautions were followed to prevent the spread of infections for one Resident (#7), out of 26 total sampled residents. Specifically, the facility failed to ensure staff implemented enhanced barrier precautions for Resident #7, who had a chronic stage three pressure ulcer. Findings include:Review of the facility's policy titled 'Enhanced Barrier Precautions', revised 2/5/25, indicated:-It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.-Initiation of Enhanced Barrier Precautions: An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers). -Implementation of Enhanced Barrier Precautions: PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities.-High-contact care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing brief or assisting with toileting, wound care: any skin opening requiring a dressing. Resident #7 was admitted to the facility in February 2024 with diagnoses including malnutrition and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/14/26, indicated Resident #7 had a severe cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. The MDS also indicated Resident #7 had a stage three pressure ulcer. Review of Resident #7's medical record indicated a diagnosis of pressure ulcer of left heel, stage 3 with an onset date of 8/4/25, which was greater than seven months ago. Review of Resident #7's Physician's Order and plan of care, dated 3/1/26-3/12/26, failed to indicate the need for enhanced barrier precautions. On 3/10/26 at 8:18 A.M. and 1:43 P.M., 3/11/26 at 7:20 A.M. and 10:48 A.M., and 3/12/26 at 7:09 A.M. and 10:25 A.M., the surveyor observed no sign that indicated the need for any precautions or precaution cart at Resident #7's doorway. On 3/11/26 at 10:49 A.M., the surveyor observed Certified Nurse Assistant (CNA) #3 assisting Resident #7 with morning care. CNA #3 said he was washing Resident #7 up and getting him/her dressed for the day. CNA #3 was not wearing a precaution gown. There was no sign that indicated the need for any precautions or precaution cart at Resident #7's doorway at this time. On 3/12/26 at 10:26 A.M., the surveyor observed Nurse #7 and Unit Manager #2 remove a soiled wound dressing and apply a new wound dressing to Resident #7's left heel. Both nurses said this was a chronic stage three pressure ulcer that Resident #7 had for more than six months, maybe even a year. Neither nurse wore a precaution gown during wound care. There was no sign that indicated the need for any precautions or precaution cart at Resident #7's doorway at this time. During a follow-up interview on 3/12/26 at 10:41 A.M., Nurse #7 said Unit Manager #2 said Resident #7 was not currently on enhanced barrier precautions. Both Nurse #7 and Unit Manager #2 were unaware chronic wounds required enhanced barrier precautions. During an interview on 3/12/26 at 10:55 A.M., the Director of Nursing (DON) said she was unaware chronic wounds required enhanced barrier precautions. During an interview on 3/12/26 at 11:12 A.M., the Infection Control Nurse said chronic wounds over three to five months require enhanced barrier precautions, including use of a precaution gown while performing high-contact activities. The Infection Control Nurse said she was unaware Resident #7 had a chronic stage three pressure ulcer for over seven months, but he/she should have had enhanced barrier precautions implemented but did not.

Based on record review and interviews the facility failed to ensure that PRN (as needed) ordered psychotropic drugs were limited to 14 days for four Residents (#32, #85, #421 and #424) out of a total sample of 26 residents. Specifically, 1. For Resident #32, the facility failed to implement a 14 day stop date for a PRN Ativan (an antianxiety medication). 2. For Resident #85, the facility failed to implement a 14 day stop date for a PRN Clonazepam (an antianxiety medication). 3. For Resident #421, the facility failed to implement a 14 day stop date for a PRN Clonazepam (an antianxiety medication). 4. For Resident #424, the facility failed to implement a 14 day stop date for a PRN Ativan (an antianxiety medication) Findings include: Review of the facility policy titled 'Psychotropic Medication Use' undated, indicated the following but not limited to: -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: -Anti-psychotic -Anti-depressants -Anti-anxiety medications and -Hypnotics. -Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -PRN orders for psychotropic are limited to 14 days. 1. Resident #32 was admitted to the facility in October 2024 with diagnoses including anxiety disorder. Review of Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the Resident #32's physician's order, dated 2/28/25, indicated the following: -Ativan (Lorazepam) 0.5 milligrams (mg). 0.25 mg by mouth PRN (as needed) nausea/vomiting once a day. Review of the Resident #32's Medication Administration Record (MAR), dated March 2025, indicated he/she received PRN Ativan on 3/4/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 2. Resident #85 was admitted to the facility in February 2024 with diagnoses including anxiety disorder. Review of Resident #85's most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of Resident #85's physician's order, dated 2/10/25, indicated the following: -Clonazepam 1 mg one tab by mouth twice a day as needed. Special instructions only two PRN doses allowed per day. Review of Resident #85's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed clonazepam on the following dates: -3/1/25, 3/3/25, 3/4/25, 3/6/25, 3/7/25, 3/8/25, 3/9/25, 3/11/25, 3/12/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, and 3/19/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 3. Resident #421 was admitted to the facility in March 2025 with diagnoses including anxiety disorder. Review of Resident #421's most recent Brief Interview for Mental Status (BIMS) dated 3/14/25 indicated the Resident scored a 15 out of a possible 15 indicating he/she was cognitively intact. Review of Resident #421's physician's order, dated 3/12/25, indicated the following: -Ativan (Lorazepam) 1 mg tablet administer one tablet by mouth every 8 hours as needed for anxiety. -Review of Resident #421's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed Ativan on the following dates: -3/13/25, 3/14/25, 3/25/25, 3/16/25, 3/17/25, and 3/18/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 4. Resident #424 was admitted to the facility in March 2025 with diagnoses including bipolar disorder, delusional disorder and anxiety. Review of Resident #424's most recent Brief Interview for Mental Status (BIMS) dated 3/10/25 indicated the Resident scored a 15 out of a possible 15 indicating he/she was cognitively intact. Review of Resident #424's physician's order, dated 3/9/25 indicated the following: -Clonazepam 0.5 mg administer one tablet by mouth twice a day for anxiety. Review of Resident #424's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed Clonazepam on the following date: -3/10/25 During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic need a 14 day stop date.

Based on observation, interviews, and record review the facility failed to maintain respiratory equipment according to professional standards of practice for one Resident (#83), out of a total sample of 26 residents. Specifically, For Resident #83, the facility failed to ensure the oxygen concentrator and filter were clean. Findings include: Review of the facility's policy, titled 'Oxygen Concentrator', dated 12/3/24, indicated the purpose is to establish responsibilities for the care and use of oxygen concentrators. -The main body cabinet should be dusted when needed and can be wiped clean with damp cloth and mild household cleaner if necessary. On 3/18/25 9:15 A.M., the surveyor observed the oxygen filter on the oxygen concentration had a layer of gray dust and the main body cabinet had a layer of powder and gray dust. Review of Resident #83's physician order, dated 2/19/24, indicated oxygen- change tubing, rinse filter, wipe down concentrator weekly. Label/date/bag tubing with each change. Once a day on Tuesday nights Review of Resident #83's Treatment Administration Record (TAR), dated 3/18/25, indicated 'oxygen-change tubing, rinse filter, wipe down concentrator weekly' was initialed as completed. On 3/19/25 at 12:25 P.M., the surveyor and Unit Manager #1 observed Resident #83's oxygen concentrator and filter. The oxygen filter was observed to have a thick layer of gray dust, and the main body cabinet had a layer of powder and dust. Unit Manager #1 said the concentrator and filter were dirty and needed to be cleaned. Unit Manager #1 said the oxygen concentrator is scheduled to be cleaned weekly with oxygen tubing change. On 3/20/25 at 9:17 A.M., the Director of Nursing said the oxygen concentrator and filter should be cleaned weekly.

Based on record review and interviews, the facility failed to implement a pharmacy recommendation for one Resident (#85) out of a total sample of 26 residents. Findings include: Review of the facility policy titled 'Medication Regimen Review' dated April 2024, indicated the following but not limited to: -Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Resident #85 was admitted to the facility in February 2024 with diagnoses including anxiety disorder. Review of Resident #85's most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the Resident score a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the consultant pharmacist recommendation to prescriber report dated 2/16/25 indicated the following: -Resident is receiving the following PRN (as needed) psychotropic medication. These medications are required to be re-evaluated after 14 days. If therapy is to be continued beyond 14 days, please note medical justification for continued use in progress note and specify the number of days the PRN order is to continue. Trazadone and Clonazepam. Review of the physician response to the pharmacy recommendation dated 2/18/25 indicated the following: -I agree - please see new order- please add 14-day re-eval for clonazepam. Review of the medical record failed to indicate a 14-day re-evaluation for clonazepam was added to the physician order. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said the pharmacy recommendations should be implemented as soon as the physician addresses them. During an interview on 3/20/25 at 9:15 A.M., the Director of Nursing said pharmacy recommendations should be addressed and implemented within 24-48 hours.

Based on record review and interview, the facility failed to follow professional standards of practice for 3 Residents (#97, #421, and #424) out of a total sample of 26 residents. Specifically; 1. For Resident #97, the facility failed to follow a physician's order for a weekly skin check. 2. For Resident #421, the facility failed to follow physician's order for air mattress setting. 3. For Resident #424, the facility failed to follow physician's order for air mattress setting. Findings include: 1. Review of the facility policy titled Prevention of Pressure Ulcers, dated April 2020, indicated the following: - Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Resident #97 was admitted in September 2023 with diagnoses including osteoarthritis and failure to thrive. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #97 scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Norton Plus Pressure Ulcer Scale (a tool used to asses risk of developing a pressure ulcer), dated 7/10/24, indicated Resident #97 was at high risk for developing a pressure ulcer. Review of the weekly skin check observations for July 2024 indicated that skin checks were completed on 7/9/24 and then again on 7/23/24. The medical record failed to indicate that a skin check was done on the week of 7/16/24. Review of the skin check, dated 7/23/24, indicated Resident #97 had a left heel pressure wound. Review of the nursing progress notes, dated 7/23/24, indicated Area to left heel measuring 3.2cm (centimeters) x 3cm. New treatment order in place. Resident encourage [sic] to elevate leg and use heel booties while in bed. During an interview on 03/19/25 at 12:09 A.M., Unit Manager #2 said that if there is an order for skin checks to be completed weekly, then skin checks should be completed. Unit Manager #2 confirmed that there was a missing skin check for the week of 7/16/24, but said that there might be information regarding the skin check in the nursing progress notes. Review of the nursing progress notes failed to indicate any documentation related to a skin check. 52138

Based on observations, record review and interview the facility failed to develop and implement a comprehensive resident-centered care plan for one Resident (#92) out of a total sample of 26 residents. Specifically, for Resident #92, the facility failed to develop a care plan for use of a psychotropic medication (used to treat or manage a psychiatric symptoms or challenging behavior). Findings include: Resident #92 was admitted to the facility in March 2023 with diagnoses including anxiety and dementia. Review of the physician orders dated March 2025 indicated the following orders: -Valproic acid (mood stabilizer) solution; 250 mg (milligrams)/5 mL (milliliters); amount 2.5 ml; oral twice a day for anxiety. Review of the current care plan for Resident #92 failed to indicate a focus, goals and interventions for the use of the mood stabilizer medication Valproic Acid. During an interview on 3/19/25 at 12:14 P.M., with Nurse #1 she said she did not know how to monitor a resident for adverse effects of a psychotropic medication. During an interview on 3/19/25 at 12:19 P.M., Nurse #2 she said she could look up any side effects of psychotropic medications and that it seems like there should be a care plan to address psychotropic medication use. Nurse #2 said she would think that there should be a care plan to address psychotropic medication use. During an interview 3/20/25 at 8:08 A.M., Unit Manager #2 said that psychotropic medication use is usually addressed in a behavior care plan, but the care plan does not address adverse effects of psychotropic medications. During an interview on 3/20/25 at 9:15 A.M., the Director of Nursing said if a resident is on a psychotropic medication they should have a care plan in place. 46339

Based on record review and interviews, the facility failed to provide quarterly financial statements for one Resident (#89) with a Personal Needs Account (PNA) out of a sample of 26 residents. Specifically, the facility failed to provide quarterly financial statements to his/her Conservator. Findings include: Resident #89 was admitted to the facility in April, 2023 with diagnoses including dementia. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) Score of 12 out of a possible 15 indicating moderate impairment. Review of the medical record indicated that Resident #89 has a decree of Conservatorship dated 12/21/23. (A Conservator is a court-appointed individual responsible for managing the financial affairs and property of a protected person who is deemed unable to do so themselves). During an interview on 3/19/25 at 10:03 A.M., the Business Office Manager (BOM) said Resident #89 has a PNA account. She said the facility has been the representative payee ( a representative payee is a person or organization authorized by the Social Security Administration (SSA) to manage and cash certain benefit checks) since 5/24/23. The BOM said she has been mailing the Resident's financial quarterly statements to his/her family member. The BOM said the Resident's family member is not legally responsible for the Resident's finances so she should not be receiving the quarterly statements. The BOM said the Resident has had a Conservatorship in place since 12/21/23. The BOM said she should be mailing the Resident's financial quarterly statements to the Conservator because she is legally responsible for the Resident's finances. During a telephone interview on 3/20/25 at 8:20 A.M., the Conservator said she has never received quarterly statements from the facility since she was appointed on 12/21/23. She said she expects the facility to mail the Resident's financial quarterly statements to her since she is legally responsible for his/her finances.

Based on interview, record and policy review, the facility failed follow professional standards for weight management for one Resident (#101) out of a total sample of 5 residents. Specifically, the facility failed to conduct reweights for weights outside of acceptable parameters per facility policy. Findings include: Review of the facility policy titled Weighing and Measuring, revised 10/2019 indicated: Residents are weighed: On admission or readmission (Do NOT use prior hospital weight) Weekly for the first 4 weeks after admission Monthly thereafter Per physician's order K. Check current weight against prior recorded weight L. Notify the licensed nurse if weight is three or more pounds different (gain or loss) from prior weight M. Re-weigh the resident within 24 hours to verify accuracy of the weight N. Record the re-weight in the Vital Signs section of the electronic medical record Resident #101 was admitted to the facility in January of 2024 with diagnoses including Type 2 diabetes mellitus (non insulin-dependent diabetes), sepsis (the presence of bacteria in the blood often associated with severe disease) and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) of 15 out of 15. Further review of Section GG of MDS indicated Resident #101 required assistance with set up and clean up of meals and of Section K indicated that he/she had weights loss of 5% or more in the last month or 10% or more in the last 6 months, not on a physician-prescribed weight-loss regimen. On 4/10/24 at 1:50 P.M., Resident #101 was observed laying in his bed. He/she said that the staff weigh him/her and say that he/she is losing weight. The Resident said that his/her appetite was not what it used to be and they offer what he/she likes. Review of the medical record indicated the following: Vitals Report (1/19/24 - 4/11/24) Resident weights: 1/20/24: 245.4 lbs (pounds) 1/27/24: 240.4 lbs 2/10/24: 227.6 lbs 2/20/24: 246 lbs 3/6/24: 231.6 lbs 3/12/24: 229.4 lbs 3/19/24: 224.4 lbs 3/26/24: 225 lbs 4/2/24: 220.6 lbs 4/5/24: 218.2 lbs 7/24: 218.2 lbs 4/9/24: 216.6 lbs Review of the medical record failed to indicate that a reweight was obtained for Resident #101 when a weight difference of three or pounds was noted on the following dates: 1/27/24, 2/10/24, 2/20/24, 3/6/24, 3/19/24 and 4/2/24. Review of the Nutrition Progress Note dated 3/27/24 at 12:22 P.M., indicated the Resident #101's weights: 3/26/24 225 lbs, 3/6/24 231.6 lbs, 2/20/24 246 lbs, 1/20/24 245.4 lbs. Possibly 1/20 and 2/20 weights were an error? Resident consumes 75%+ of most meals. He/she enjoys meals with a good appetite. During an interview on 4/11/24 at 11:24 A.M., the Registered Dietician said that the policy of the facility was that if a resident's weight changes by 3 pounds from the previous weight, a re-weight needs to be done and documented. She said she expects the weight change to be reported to her so she can determine interventions based on the clinical needs and the resident's wishes. She said there is a weekly At Risk meeting that she attends, but if weights are not in the record, she cannot make recommendations. She said Resident #101 is eating, asking for snacks, refuses Glucerna and large portions, says he/she doesn't want more food. He/She has clinical issues and is hypermetabolic so even though he/she eats a lot, he/she is burning a lot. During and interview on 4/11/24 at 12:15 P.M. with the Director of Nursing (DON) and Quality Assurance (QA) Nurse, the DON said she expects the nurses to follow the Weight Policy. Weights should be done on admission, then weekly for 4 weeks, if there is a weight loss/gain 3 pounds or more, a reweight should be done and recorded. If weight is validated, nursing should talk with the resident, notify the physician and dietitian. She said the facility has weekly weight and wound (At Risk) meetings, and risk notes should be put into medical record so they can always refer back to chart with any changes. She said that the risk notes did not make it into Resident #101's medical record.

Based on observation, record review and interview, the facility failed to provide supervision and cuing during meals per the plan of care for 2 Residents (#87, #106) out of a total of 22 sampled Residents. Findings include: 1. Resident #87 was admitted to the facility in November 2020 with diagnoses including Alzheimer's disease and depression. Review of Resident #87's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 3 out of a possible 15 on the Brief Interview for Mental Status Exam indicating severe cognitive impairment. Additional review of the MDS indicated Resident #87 required physical assistance with bathing and dressing and supervision with eating. On 4/4/23 at 11:47 A.M., the surveyor observed staff deliver Resident #87's lunch meal to his/her room. Staff left his/her tray on the bedside table and left the room. At 12:12 P.M., the surveyor observed Resident #87 asleep in bed with his/her plate untouched, except for some bites of pudding. Resident #87 woke and said that he/she was not hungry and wanted to sleep. Review of Resident #87's Activities of Daily Living Care Plan dated 11/3/20, review date 2/22/23 indicated: Eating, assist and prompt with cues and encouragement to complete meal. Review of the Dietitian's Quarterly assessment dated [DATE] indicated: Resident with a 14 lb 10% weight loss in 6 months. Staff provides cueing and encouragement with meals. On 4/5/23 at 8:02 A.M., the surveyor observed Resident #87 in his/her room adjusting his/her bedding. Resident #87's breakfast tray was on the bedside table and was untouched except for 2 bites from his/her breakfast sandwich. Resident #87 asked the surveyor what was on the breakfast tray and then asked if he/she could go back to sleep. There were no staff providing cueing or encouragement per his/her plan of care. On 4/5/23 at 11:48 A.M., the surveyor observed Resident #87 seated at the side of his/her bed and then adjust himself/herself into a laying position. Resident #87's lunch meal was on his/her bedside table untouched except for some bites of pudding. There was no staff providing cuing or encouragement per his/her plan of care. On 4/6/23 7:47 A.M., the surveyor observed CNA #1 deliver Resident #87's breakfast meal to his/her room, set up the tray and leave. The surveyor then approached CNA #1 who said that Resident #87 requires set up for meals and eats by himself/herself in his/her room. CNA #1 said that Resident #87 is not a big eater. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M., she said that Resident care plans should be followed. 2. Resident #106 was admitted to the facility in July 2022 with diagnoses including Review of Resident #106's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. The MDS also indicated Resident #106 requires supervision with meals. On 4/4/23 at 8:16 A.M., the surveyor observed Resident #106 eating breakfast alone in his/her room. Resident #106 appeared thin and frail and was coughing after taking bites of his/her meal. There was no staff in the room providing assistance or supervision. Review of Resident #106's Physician's Orders indicated the following: 1:1 assistance with all meals, Aspiration precautions with meals, 3/27/23. Review of Resident #106's nursing progress note indicated the following: Seen by speech, diet changed to ground fortified foods with moderately thick liquids. 1:1 assistance with all meals and aspiration precautions, 3/27/23. Review of Resident #106's Nutrition Care Plan, dated 7/19/22 indicated an intervention for Resident #106 to be 1:1 with meals due to aspiration precautions. On 4/5/23 at 8:26 A.M., the surveyor observed Nurse #1 deliver Resident #106's breakfast meal to his/her room. Nurse #1 set up the tray and then left the room. At 8:32 A.M. the surveyor observed Resident #106 eating his/her meal alone his/her room without supervision per his/her plan of care. On 4/5/23 at 12:06 P.M., the surveyor observed Resident #106 seated in the dining room with 3 other Residents at his/her table eating his/her meal. There were no staff seated with Resident #106 providing 1:1 per his/her care plan. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M., she said that Resident care plans should be followed.

Based on observation, record review and interview, the facility failed to identify and address a significant weight loss for 1 Resident (#7) out of a total of 22 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2022 with diagnoses including Parkinsons, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of Resident #7's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Additional review of the MDS indicated that Resident #7 requires assistance with bathing, dressing and transfers. During an interview on 4/4/23 at 9:48 A.M., Resident #7 appeared thin and frail. Resident #7 said that he/she forces himself/herself to eat. Review of Resident #7's Nutritional Status Care Plan, initiated 8/11/22, indicated the following interventions: Diabetic snack at HS (hour of sleep). Diet: Regular solids, fortified foods, no fish. Honor preferences within diet. Offer menu selection. Monitor Intake. Fortified foods; super cereal daily with breakfast, super pudding daily with lunch. Supplements; Ensure plus high protein 8 oz BID (twice daily), Weight; monthly. Review of Resident #7's physician's orders indicated orders for Ensure twice daily, (initiated 9/22/22) and fortified food with meals, (initiated 10/12/22). Review of Resident #7's weights indicated the following: 1/2/23: 106.4 lbs (pounds) 2/5/23: 98.8 lbs a loss of 7.14% of his/her total body weight in one month 3/6/23: 97 lbs 4/2/23: 99 lbs Review of the clinical record indicated that Resident #7 was not assessed by the Dietitian until 3/22/23: 46 days after the weight loss was first identified. Review of the Dietitian's assessment failed to identify Resident #7 had a significant weight loss between January 2023 and February 2023 and failed to introduce new interventions in response to the weight loss. Review of the facility's Risk Meeting minutes failed to include Resident #7 in the February 2023 or March 2023 meetings for significant weight loss. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M. she said that Resident #7 had a weight loss although he/she does have a good appetite. Charge Nurse #1 said that Resident #7 is a picky eater and sometimes orders out and a friend comes and visits once a month and will bring in food. Charge Nurse #1 said that Resident #7's family hasn't been to visit as frequently. During interviews with the Dietitian on 4/6/23 at 12:30 P.M. and 12:52 P.M. she said that she in the facility 20 hours a week and is alerted by the staff of any new weight loss and also can run a report through the electronic health record. The Dietitian acknowledged she did not assess Resident #7's weight loss until 3/22/23 for his/her Quarterly assessment. The Dietitian said she did not introduce any new interventions addressing Resident #7's weight loss because it was reported to her that Resident #7 often refuses his/her Ensure supplement and the Resident's family also frequently brings in snacks and food items for Resident #7. The Dietitian said he/she was not aware that the Treatment Administration Records (TAR) for February 2023 and March 2023 indicated that Resident #7 only refused the Ensure 3 times. The Dietitian said that she was also not aware that staff had reported that Resident #7's family had not been visiting regularly. The Dietitian did not say if the use of an appetite stimulant, larger portions, or other interventions had been considered.

Based on policy review, observations, record review and staff interviews, the facility failed to obtain physician's orders for oxygen administration for one Resident (#1), in a total sample of 22 residents. Findings include: Review of the facility policy titled, Oxygen Therapy, dated as revised 2/2022, indicated: -an order by the physician or designee must be in the resident's record indicating the oxygen equipment and flow rate of oxygen desired. Resident #1 was admitted to the facility in February 2023 with diagnoses including end stage renal disease, atrial fibrillation, heart failure, hypoxemia (low oxygen). Review of the Minimum Data Set (MDS) assessment, dated 3/3/23, indicated Resident #1 required oxygen administration. Review of the Hospital Discharge Summary, dated 2/28/23, indicated that Resident #1 required continuous oxygen administration. During observations on 4/4/23 at 8:39 A.M., 4/4/23 at 1:33 P.M., 4/4/23 4:02 P.M., and on 4/5/23 at 6:50 A.M., Resident #1 was in his/her room receiving oxygen via nasal cannula. Review of the physician's orders dated 2/28/23-4/5/23, indicated there was no documentation to support an active physician's order for Resident #1's oxygen administration. During an interview on 4/6/23 at 11:52 A.M., the Charge Nurse #2 said that oxygen administration requires a physician's order. During an interview on 4/6/23 at 10:20 A.M., the Quality Assurance Nurse said that oxygen administration requires a physician's order. During an interview on 4/6/23 at 2:04 P.M., the Director of Nursing said that oxygen administration requires a physician's order.

Based on observation, record review and interview, the facility failed to provide counseling services for 1 Resident (#7) out of a total of 22 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2022 with diagnoses including Parkinsons, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of Resident #7's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Additional review of the MDS indicated that Resident #7 requires assistance with bathing, dressing and transfers. During an interview on 4/4/23 at 9:48 A.M., Resident #7 was tearful and anxious. Resident #7 said that he/she was depressed and noted he/she had lost his/her child, was missing his/her family and did not want to be in a long term care facility for the rest of his/her life. Review of Resident #7's clinical record indicated a referral/screening request form dated 9/28/22 for Resident #7 to receive individual counseling from psychiatric services for individual counseling due to anxiety, depression, and adjustment. Review of the clinical record failed to indicate that Resident #7 had received any counseling services since his/her admission to the facility. During an interview with Social Worker #1 on 4/5/23 at 12:35 P.M. she confirmed the referral was placed but did not know why Resident #7 had not been seen for counseling services.

Based on interview, record review and observation, the facility failed to 1. ensure it followed Center for Disease Control (CDC) requirements for assessing in-person visitation for signs and symptoms of COVID-19 and exposure to others with suspected or confirmed [CONDITION(S)]-CoV-2 infection, 2. perform proper hand hygiene, 3. maintain social distancing between residents during an outbreak, 4. practice proper glove use when administering insulin, and 5. wear the proper personal protective equipment (PPE) when entering a COVID positive room. Findings include: 1. The Centers for Disease Control (CDC) guidance for Nursing Home Visitation - Covid-19 (revised 11/12/2021), indicated: Visitors who have a positive [CONDITION(S)] test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility. Facilities should screen all who enter for these visitation exclusions. Four surveyors entered the facility on 1/4/2022 at approximately 7:05 A.M. and observed Nurse #1 behind the front lobby desk. Nurse #1 greeted the surveyors and asked if they were vaccinated and, if not vaccinated, asked that they take a rapid [MEDICATION(S)] test. The surveyors declined the rapid [MEDICATION(S)] test. Nurse #1 then left the desk and escorted the surveyors to a conference room. Nurse #1 did not ask the surveyors if they had tested positive for COVID-19 or met criteria for quarantine. The staff person did not ask the surveyors if they had symptoms of the illness (such as coughing, headache, myalgia, fever, or difficulty breathing), or were exposed to COVID-19. Facility staff did not offer the surveyors a questionnaires or other means of screening for COVID-19. A temperature gauge was in the lobby, but Nurse #1 did not ask the surveyors to take their temperatures. The surveyors did not take their temperatures. During an interview with the Infection Control Nurse on 1/6/2022 at 8:30 A.M., the surveyor told them that staff did not screen the four surveyors on 1/4/2022. The Infection Control nurses said it was CDC guidance and facility policy for all visitors to be screened for COVID-19. The Infection Control Nurses said that the facility required all visitors to take their temperature, record the temperature on a written questionnaire, and to document answers to screening questions about their COVID-19 status and possible exposure to the virus. Review of the facility ' s policy for Completing the COVID-19 Screening Checklist, dated 12/23/2021, indicated staff were to ask visitors if they had symptoms of COVID-19, to take the visitor's temperature, ask the visitor if they had been exposed to COVID-19, ask their vaccinations status, and if the visitor would like to be tested for COVID-19. The policy indicated staff were to ensure that the visitor washed hands before entering the building. 2. On 1/04/22, at 11:11 A.M., the surveyor observed Certified Nurse's Aide (CNA) #4 boost a resident in bed and then exit the room without performing hand hygiene (HH) while carrying a pair of soiled slippers and 2 bags of soiled laundry. CNA #4 then walked down the hall to the dirty utility room to dispose of the slippers and soiled laundry, contaminating the door handle. She then obtained a clean protective gown from the hallway linen closet, contaminating it. CNA #4 then walked back to the resident's room and without performing HH upon entering, donned the contaminated gown, donned gloves (contaminating them), obtained a shirt from the closet (contaminating the closet handles and the shirt) and placed the contaminated shirt on the resident. During an interview on 1/04/22, at 11:14 A.M., CNA #4 said she should have washed her hands before exiting and entering the resident's room. 3. On 1/05/22 at 2:21 P.M., the surveyor observed an activity in the Baker unit dining room where 8 residents were without masks and sitting within 2 feet from each other. 2 staff members were present during the activity and did not encourage the residents to don a mask. 4. a. During medication pass on 1/5/22, at 8:51 A.M., the surveyor observed Nurse #3 administer 15 units of Novolog insulin to a resident without wearing gloves. b. During medication pass on 1/5/22 at 9:07 A.M., the surveyor observed Nurse #3 don gloves without performing hand hygiene and then administer 34 units of [MEDICATION(S)] insulin to a resident. Review of the facility policy titled Injectable Medication Administration and dated 2017, indicated that hand hygiene is to be performed before donning gloves and gloves are to be worn during the administration of injectable medications. 5. During an observation on 1/6/2022 at 8:41 A.M., Nurse #4 walked put a gown on to enter a COVID positive resident's room. Nurse #4 was wearing a KN95 mask and not an N95 respirator. After entering the COVID positive room, Nurse#4 proceeded to exit the room with the reusable gown, grab medication, then re-enter the COVID positive room. When Nurse #4 was exiting the room for the final time, he disposed of the gown and performed hand hygiene, but did not wipe his potentially contaminated goggles with disinfectant and did not dispose of his mask.

Based on record review and interview, the facility failed to assess an open wound for 1 Resident (#12) out of a total sample of 20 residents. Findings include: Review of the facility policy, titled Pressure Injury Prevention & Treatment Program, revised 01/2018, indicated the following: *This facility is committed to providing a comprehensive, interdisciplinary, and evidence-based approach to: Implement individualized person-centered interventions to attempt to stabilize, reduce or remove underlying risk factors Monitor the impact of the interventions Modify interventions as appropriate Assessments are timely and appropriate *Policy: Skin checks are completed weekly on all residents and documented Wounds will be reassessed at least once a week, with accurate measurements, and comprehensive documentation Resident #12 was admitted in 02/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #12's progress notes indicated that on 11/13/2021, two small open areas and a small red area were identified on Resident #12's coccyx. Review of the progress notes after 11/13/2021 do not indicate that any documentation had been completed on the wounds. Review of the Weekly Skin Checks indicated the following: 11/20/21: Coccyx- open areas/[MEDICATION(S)] applied 12/18/21: Coccyx- open areas/[MEDICATION(S)] applied Review of the record did not indicate that any wound measurements had been taken to assess the status of the wound. During an interview on 1/5/2022 at 2:09 P.M., the Director of Nursing (DON) said that she tries to have risk meetings monthly where they discuss wounds. The DON said that if a new wound is identified it is expected that an incident report be done and a good description is written with measurements and the wound should be offloaded. The wound should be looked at every shift and nurses should document in the progress notes or weekly skin checks. Review of the clinical record did not indicate that any measurements or descriptions had been completed for two open areas on Resident #12's coccyx.

Based on observation, interview, and record review, the facility failed to 1. provide assistance at meals for 1 Resident (#4) and 2. provide grooming assistance for 2 Residents (#44 and #249) out of a total sample of 20 residents. Findings include: 1. Review of the facility policy, titled Supervision and Assistance During Meals, revised 04/2018, indicates the following: *It is the policy of the facility to provide supervision/assistance to residents during meals as needed to promote safe strategies and adequate intake. *Continual Supervision- no more than 1 staff member to eight residents during the entire meal Resident #4 was admitted in 05/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #4 has severe cognitive impairment and requires extensive assist with eating and self-performance and one assist with eating support. Review of the current care plan for Resident #4 indicated the following: *Problem: deficit in ADL's (activities of daily living) *Approach: Meals- Continuous supervision to assist Review of the speech therapy discharge note, dated 1/26/2021, indicated that Resident #4 required close supervision at meals. During an observation on 1/4/2022 at 12:30 P.M., Resident #4 was eating in his/her room alone with food on his/her chest. During an observation on 1/5/2022 at 12:09 P.M., Resident #4 was eating in his/her room alone. During an observation on 1/6/2022 at 8:44 A.M., Resident #4 was eating in his/her room alone. During an interview on 1/6/2022 at 9:56 A.M., CNA #1 said that Resident #4 usually eats in the dayroom, but when he/she does not get up then a staff member is supposed to sit with him/her during meals. 2. Review of the facility policy titled Personal Hygiene and Bathing, dated revised 9/2018, indicated to assist resident with grooming as needed. a. Resident #44 was admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/28/21, indicated that Resident #44 required an extensive assist with grooming. On 1/04/22, at 7:52 A.M. and 1:46 P.M., the surveyor observed Resident #44 in the dining room with hair on her/his chin. On 1/05/22 at 9:34 A.M. the surveyor observed Resident #44 in bed with 1 inch long hair on her/his chin. On 1/05/22, at 2:16 P.M., the surveyor observed Resident #44 in the dining room with 1 inch long hair on her/his chin. On 1/06/22, at 7:301 A.M., the surveyor observed Resident #44 in bed with 1 inch long hair on her/his chin. During an interview on 1/06/22, at 8:59 A.M., Nurse #1 said that the nurse's aides are responsible for making sure chin hair is removed During an interview on 1/06/22, at 9:01 A.M., Certified Nurse's Aide (CNA) #2 said that it was the responsibility of the CNA's to remove the facial hair on both males and females when the beautician isn't available. b. Resident #249 was admitted to the facility in December 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 12/27/21, indicated that Resident #249 required an assist with grooming. On 1/04/22, at 7:58 A.M. and 1:50 P.M., the surveyor observed Resident #249 with hair on her/his chin. On 1/05/22 at 9:37 A.M. the surveyor observed Resident #249 with 1 inch long hair on her/his chin. On 1/05/22, at 2:20 P.M., the surveyor observed Resident #249 with 1 inch long hair on her/his chin. On 1/06/22, at 7:35 A.M., the surveyor observed Resident #249 in bed with 1 inch long hair on her/his chin. During an interview on 1/06/22, at 7:38 A.M., Resident #249 said she/he wants the hair to be removed and doesn't like it there.

Based on record review and interviews, the facility failed to provide supervision and use of a chair alarm for one closed resident record (Resident #248) out of a sample of 3 discharged resident's records. Resident #248 fractured his/her hip as a result of the fall. Findings include: Resident #248 was admitted ,[DATE] with the following Diagnoses: [REDACTED]. The resident, on a fall risk scale, dated 9/27/17, scored a 65, placing the resident at a high risk for falls. The fall risk scale numbers remained high throughout his/her stay. Review of the resident's Minimum Data Set (MDS), indicated that the resident required assistance with all activities of daily living, mobility and transfers. The MDS also indicated that the resident had difficulty communicating and was cognitively impaired. Review of the Resident #248's care plans for falls included the following information: *Complete Fall Risk Assessment *Implement the following safety measures: *Chair alarm and bed alarms These interventions were evaluated and active from 1/17 to 10/17. The resident's plan of care included the resident required the use of a chair and bed alarm and required assist with ADL's, mobility and transfers. On 9/24/17 Resident #248, who had a history of [REDACTED]. Another resident was the one who called out for help. Resident #248 sustained a left femur (thigh bone) fracture. Resident was found to have hit his/her head, cut one of his/her hands and a hospital CT scan of left hip indicated that the resident had a non-displaced subcapital [MEDICAL CONDITION] femur. In an interview with Charge Nurse #1, she said that residents who need supervision are usually placed into an activities area or dining area which serves as a point of observation and supervision. She added that no one was watching the resident while he/she was in the day room prior to the fall. Charge Nurse #1 said that she was not aware of what level of supervision the resident required and did not know about the alarm being missing. There were no care plans regarding how the facility was providing supervision to the resident. Due to the nature of the resident's injury, a report was sent to the Department of Public Health. The statement from CNA #1 indicated that she was unaware that the resident needed a bed and chair alarm, she only knew of the bed alarm. The report indicated that staff were in-serviced. The resident returned from the hospital with a non displaced fracture that required a mechanical lift for transfer and was total care for activities of daily living.

Based on observations, interviews, and record review, the failed failed to prevent a pressure sore from developing on the right medial malleolus (ankle) of 1 of 3 applicable sampled residents (Resident #1) with pressure sores from a total sample of 24 residents. Findings included: Review of Resident #1's clinical record on 9/13/12 indicated the resident was admitted to the facility in August 2012, with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), dated [DATE], indicated that the resident had no cognitive deficits, required the physical assistance of one staff member for transfers and ambulation, and had no pressure sores. Review of the admission physician orders, dated 8/29/12, indicated that the resident was to wear an air cast on the right foot when ambulating. The admission orders [REDACTED] Review of the admission nursing assessment, dated 8/29/12, indicated the resident: was alert and oriented; was able to bear full weight as tolerated on the right ankle, and was to use a rolling walker with the assistance of one staff member for ambulation. The assessment indicated numerous ecchymotic (bruised) areas on both the upper and the lower extremities and no open areas on either ankle were noted. Review of the plan of care for the potential for skin breakdown, dated 8/29/12, indicated that the resident's skin was to be inspected weekly and/or as needed, and the findings needed to be recorded. Review of the nursing progress note, dated 8/30/12 at 2:30 P.M., indicated the resident was ambulating with the rolling walker in his/her room and the air cast was in place on the right foot. The note indicated that the resident denied pain. Review on 9/14/12 of the physical therapy progress note by Physical Therapy Assistant (PTA) #1, dated 8/31/12 at 2:30 P.M., indicated that the resident was wearing the right lower extremity air cast. The progress note indicated that the resident presented with pain in the right ankle. The progress note further indicated that when PTA#1 removed the resident's air cast, blood was present on his/her ankle. During an intervew with PTA #1 on 9/14/12 at 9:45 A.M., she said she immediately called a nurse to observe the resident's right ankle on 8/31/12, when she observed blood on his/her ankle. PTA #1 said there was an open lesion (unable to remember the size) where the air cast touched the skin just below the right ankle. PTA #1 said the nurse applied a bandage and placed the air cast on the resident's right ankle. PTA #1 said that when when she returned to the resident's room later in the morning, she observed him/her standing unattended in the room without the rolling walker. She reported this observation to nursing staff. Review of the nursing progress note, dated 8/31/12 at 12:00 P.M., indicated that the resident was noted to be self-transferring. There was no documentation in the nursing progress note that the resident's right ankle had a bandage applied to the area on the ankle. Review of the nursing progress note, dated 9/2/12 at 1:00 P.M., indicated that the resident had a right inner malleolus open lesion measuring 0.6 centimeters (cm) by 1 cm and oblong in shape. The note indicated that the physician was notified. The physician ordered the right ankle lesion to be washed with normal saline, pat dry, and apply [MEDICATION NAME] (a protective dressing) daily until healed. Review of the Pressure Ulcer (Sore) Identification and Progress Note, dated 9/4/12, indicated that the pressure sore was considered a stage III due to the 100% presence of slough (a layer of dead tissue separated from the surrounding living tissue) on the pressure sore. The pressure sore measured 1.3 cm by 1.3 cm with scant drainage, no odor, and no undermining. Review of the resident's weekly skin check, dated 9/6/12, indicated that the pressure sore was being treated. Review of the nursing progress note, dated 9/10/12, indicated that the right ankle wound was noted to be macerated (soft) and the physician was notified. Review of the physician orders, dated 9/10/12, indicated that the physician changed the resident's treatment order for the right ankle to the following: wash with normal saline, pat dry, apply Santyl (a [MEDICATION NAME] agent) ointment to the open area, and cover with a dry protective dressing until healed. Observation of the resident's right ankle on 9/13/12 at 1:15 P.M., revealed a 1.3 cm by 0.75 cm pressure sore with scant bloody drainage, the edges of the wound were defined, and the surrounding tissue pink. During interview on 9/14/12 at 1:15 P.M., Unit Manager #1 said there was no documentation of the resident's right ankle open lesion from 8/31/12 until 9/2/12 in the nursing progress notes until a physician's orders [REDACTED]. She said the resident's right ankle open lesion was determined to be a stage III pressure sore because slough was present in the wound when first observed by a nurse on 9/2/12. Unit Manager #1 said that because the resident wore an air cast when ambulating, nursing staff should have observed the surrounding skin on the right ankle after the air cast was removed for possible skin breakdown.

Based on record review and interviews, the Facility failed to ensure that allegations of abuse by either Accused CNA #1, Accused CNA #2, Accused CNA #3 or Accused CNA #4 involving 7 of 41 sampled residents (Residents #1, #2, #5, #6, #7, #10 and #17), occurring between November 2010 to February 2011, were reported to the Administrator or to the Department of Public Health when at least 7 Facility staff members at different periods in time, observed abuse, but failed to ensure the Administrator was notified. In addition, Resident #1 was videotaped and an unidentified resident photographed and the images were disseminated on employees' cellular phones. Resident #2, #5, #6, #7, #10 and #17 were victims of repeated taunts, humiliation and curses which occurred in the presence of other staff members, but these actions were not reported to the Facility administrator until 2/3/11. Findings included: 1. Review of the Facility's report, dated 2/10/11, indicated that a staff member substantiated that in 2010, Accused Certified Nursing Assistant (CNA) #1 showed another staff member a video of a resident on Accused CNA #1's cellular phone. This was not reported to the Administrator at the time the incident occurred in March 2010. 2. CNA #3 was interviewed at 1:09 P.M. on 3/17/11 and at 3:20 P.M. on 3/23/11. CNA #3 said that CNA #3 was working with Accused CNA #2 during an evening shift when Accused CNA #2 received a photograph on Accused CNA #2's cellular telephone. CNA #3 said that the picture was of a resident, who CNA #3 could not identify, seated on the toilet and not fully clothed. CNA #3 said that the unidentified resident appeared to be in the process of receiving care or using the toilet. CNA #3 said that Accused CNA #2 told CNA #3 that Accused CNA #4 was working at another facility (Facility #2), and Accused CNA #4 took the photograph of a resident of Facility #2, and sent it to Accused CNA #2. CNA #3 said that the incident was not immediately reported to the Facility Administrator or the Department of Public Health, until approximately one week after 2/15/11, the day of the unannounced survey. CNA #9 was interviewed at 5:00 P.M. on 3/22/11. CNA #9 said that, on more than one occasion, CNA #9 observed Accused CNA #1 taking photographs with Accused CNA #1's cellular telephone in residents bedrooms. CNA #9 said that though CNA #9 did not know what was being photographed, residents were present in the room at the time the photographs were taken. There was no indication that at the time of the incident, CNA # 9 reported this incident to the Administrator or Department of Public Health. 3. CNA #2 was interviewed at 1:39 P.M. on 3/17/11 and at 3:15 P.M. on 3/23/11. CNA #2 said that Accused CNA #3 was heard telling Resident #2 words to the effect of, "I [***] your husband every night and while he is [***] ing me, he tells me I am better in bed than you are" and "he (the husband) is leaving you", or words to that effect. There was no indication that, at the time of the incident, CNA #2 reported the incident to the Administrator. CNA #3 was interviewed at 1:09 P.M. on 3/17/11 and at 3:20 P.M. on 3/23/11. CNA #3 said that Accused CNA #1 and Accused CNA #2 would be observed repeating back to Resident #2 the words that Resident #2 said out loud during care. CNA #3 said that it appeared that during times when Resident #2 was not agitated, the comments were made by Accused CNA #1 and Accused CNA #2 in an effort to cause Resident #2 to become agitated and cause the behaviors to escalate. There was no indication that, at the time of the incident, CNA #3 reported the incident to the Administrator. CNA #4 was interviewed at 11:30 A.M. on 3/23/11. CNA #4 said Resident #2 was confused and often made sexual comments during personal care. CNA #4 said that, at times, Resident #2 would become agitated with personal care. CNA #4 said that Accused CNA #1 was heard and observed making fun of Resident #2 by referring to Resident #2's "dickie" (Resident #2's word for vagina) and saying "I am gonna [***] your dickie", or words to that effect. CNA #4 said that Accused CNA #2 was standing in the doorway and laughing at the scene. CNA #4 said that in response, Resident #2 would become agitated and more resistive to care and Accused CNA #2 would laugh even more. There was no indication that, at the time of the incident, CNA #4 reported the incident to the Administrator. 4. CNA #1 said that Accused CNA #1 and Accused CNA #4 were observed to speak to Resident #5 in a mocking manner. CNA #1 said that when Resident #5 would say sexually inappropriate things to the staff, the Accused would encourage Resident #5 by repeating back to Resident #5 what Resident #5 had said. When asked how often this was observed, CNA #1 said that it appeared to be a routine occurrence, but was unable to provide any specifics regarding the number of times this was observed. There was no indication that, at the time of the incident, CNA #1 reported the incident to the Administrator. CNA #3 said that Accused CNA #3 was heard asking Resident #5 about the penile implant and that Accused CNA #1 and Accused CNA #2 would encourage Resident #5 to "talk dirty and foul". CNA #3 was unable to elaborate as to the specifics of the conversations. There was no indication that, at the time of the incident, CNA #3 reported the incident to the Administrator. CNA #4 said that Accused CNA #1 was heard on more than one occasion, during the fall and winter of 2010, asking Resident #5 to pump up Resident #5's penile implant. CNA #4 said that Resident #5 would respond in anger and yell and curse at Accused CNA #1 to stop, and that Accused CNA #1 would then laugh at Resident #5. There was no indication that, at the time of the incident, CNA #4 reported the incident to the Administrator. Review of CNA #6's written statement, dated 2/08/11, indicated that CNA #6 observed Accused CNA #1 and Accused CNA #4 encourage Resident #5 to talk about Resident #5's penile implant and whether Resident #5's wife liked the implant. There was no indication that, at the time of the incident, CNA #6 reported the incident to the Administrator. CNA #10 was interviewed at 7:19 P.M. on 3/28/11. CNA #10 said that after the Accused CNAs were no longer working at the Facility, Accused CNA #1 told CNA #10 the reasons why Accused CNA #1 was no longer at the Facility. CNA #10 said that Accused CNA #1 admitted to "sexually harassing" two male residents, or words to that effect. CNA #10 said that Accused CNA #1 told CNA #10 that Accused CNA #1 would tell Resident #5 to pump up the penile implant because Accused CNA #1 wanted to "use it", or words to that effect. CNA #10 said that Accused CNA #1 told CNA #10 that Accused CNA #1 "just wanted to have fun" with Resident #5, or words to that effect. There was no indication that, at the time of the incident, CNA #10 reported the incident to the Administrator. 5. CNA #1 said Accused CNA #1 and Accused CNA #4 were observed speaking to Resident #6 in a mocking manner. CNA #1 said that Resident #6 was known to call out for assistance, such as "Nurse, Nurse, Nurse!", or words to that effect. CNA #1 said that Accused CNA #1 and Accused CNA #4 were observed and heard mimicking Resident #6 in Resident #6's presence. CNA #1 said that in response Resident #6 would become upset and the behavior worsened. CNA #1 said that in response Accused CNA #1 and Accused CNA #4 laughed at Resident #6 in Resident #6's presence. There was no indication that, at the time of the incident, CNA #1 reported the incident to the Administrator. CNA #2 said that on one occasion when Resident #6 was in bed and agitated and crying out, Accused CNA #3 entered the bedroom and walked past CNA #2. CNA #2 said that Accused CNA #3 told Resident #6 "your husband never loved you" and "your family never loved you and that is why you are here; and you are going to die here", "We love (Resident #2) so much more than you. Nobody likes you " , or words to that effect. There was no indication that, at the time of the incident, CNA #2 reported the incident to the Administrator. CNA #2 said that Accused CNA #1, Accused CNA #2 and Accused CNA #3 told Resident #6 that Resident #6 was "fat", or words to that effect. CNA #2 said that on one occasion Accused CNA #3 shoved a cookie in Resident #6's mouth and when Resident #6 coughed and spit the cookie out Accused CNA #3 called Resident #6 a "pig", or words to that effect. There was no indication that, at the time of the incident, CNA #2 reported the incident to the Administrator. Review of CNA #2's written statement (undated) indicated that CNA #2 observed Accused CNA #1 and Accused CNA #2 tell Resident #6 that Resident #6 was "so annoying", "your disgusting, you're covered in[***], or words to that effect. There was no indication that, at the time of the incident, CNA #2 reported the incident to the Administrator. 6. CNA #2 said that on one occasion Accused CNA #1 and Accused CNA #2 were in the bathroom providing care to Resident #7. CNA #2 said that CNA #2 remained outside the bathroom but heard Accused CNA #1 and Accused CNA #2 telling Resident #7 they wanted Resident #7 to tell them about Resident #7's being a victim of spousal abuse. CNA #2 said that, initially, Resident #7 told Accused CNA #1 and Accused CNA #2 that Resident #7 preferred not to talk about the issue, but Accused CNA #1 and Accused CNA #2 repeatedly asked Resident #7 "tell me about how he used to beat you", or words to that effect. CNA #2 said that Accused CNA #1 and Accused CNA #2 offered to assist Resident #7 to recall the details of the alleged abuse. CNA #2 said that Resident #7 became tearful and begged Accused CNA #1 and Accused CNA #2 to stop their questions, but both Accused CNA #1 and Accused CNA #2 laughed openly at Resident #7. CNA #2 said that CNA #2 entered Resident #7's bathroom and told Accused CNA #1 and Accused CNA #2 to stop their behavior, but they told CNA #2 to get out of the room and slammed the door behind CNA #2. CNA #2 said that CNA #2 reported the incident to Nurse #6, who told CNA #2 that Nurse #6 did not believe CNA #2's report. CNA #2 said that Nurse #6 told CNA #2 that it was best for CNA #2 not to meddle in other people's business. There was no indication that, at the time of the incident, Nurse #6 reported the incident to the Administrator. 6. Review of CNA #2's written statement (undated) indicated that CNA #2 observed Accused CNA #3 tell Resident #10 that Resident #10's [MEDICAL CONDITION] bag smelled. CNA #2 indicated that Resident #10 became tearful and asked Accused CNA #3 for forgiveness. There was no indication that, at the time of the incident, CNA #2 reported the incident to the Administrator. See F 223.

Based on record review and interviews, the Facility failed to ensure that 7 of 41 sampled residents (Resident #2, #15, #16, #17, #18, #19 and #20) were treated by staff in a dignified manner when multiple staff members witnessed Accused CNA #1, Accused CNA #2, and Accused CNA #3 using profane language, texting on cellular phones and playing inappropriate music while providing personal care, talking about their sexual lives and alleged drug use in the presence of residents, mocking mentally ill residents and taunting residents to avoid providing needed care. The findings included: 1. Review of CNA #1's written statement (undated) indicated that on unspecified dates CNA #1 observed Accused CNA #1 and Accused CNA #2 using inappropriate language and talking about their bar room experiences while in the presence of residents. CNA #1 was interviewed at 1 P.M on [DATE]. CNA #1 said that on more than one occasion, CNA #1 heard Accused CNA #1 swear on a regular basis in the presence of residents. CNA #10 was interviewed at 7:19 PM on [DATE]. CNA #10 said that CNA #10 worked with Accused CNA #1, Accused CNA #2, and Accused CNA #3 on a regular basis. CNA #10 said that Accused CNA #1, Accused CNA #2, and Accused CNA #3 consistently swore, and used phrases such as "[***] this" or [***] that" when speaking amongst each other when providing care to residents. 2. Review of CNA #2's written statement (undated) indicated that on unspecified dates Accused CNA #1, Accused CNA #2 and Accused CNA #3 used their personal cellular phones to transmit and receive texts and playing audibly inappropriate music on their cellular phones while providing care to residents in their bedrooms. CNA #2 indicated that Accused CNA #1, Accused CNA #2 and Accused CNA #3 sometimes told residents they would have to wait to receive their care until they were finished texting their friends. 3. Review of CNA #2's written statement indicated that, beginning in [DATE], CNA #2 observed Accused CNA #1, Accused CNA #2 and Accused CNA #3 cursing, talking about their personal sex lives, talking about Resident #2's sex life in the presence of Resident #2, talking about their use of street drugs and purchasing street drugs while providing care to Resident #2. CNA #2 was interviewed at 1:39 PM on [DATE] and on [DATE] at 3:15 P.M. CNA #2 said that on an unspecified date CNA #2 observed Accused CNA #1 and Accused CNA #2 providing care to Resident #15 in the bathroom. CNA #2 said that Accused CNA #1 and Accused CNA #2 were talking about how frequently they had sexual intercourse with their boyfriends and their favorite sexual positions. CNA #2 said that CNA #2 told Accused CNA #1 and Accused CNA #2 that this was not the place for this conversation. CNA #2 said that Accused CNA #1 and Accused CNA #2 told CNA #2 that Resident #15 did not understand their conversation because Resident #15 had [MEDICAL CONDITION]. 4. CNA #2 said that beginning in approximately early November, 2010, to February, 2011, CNA #2 observed Accused CNA #1 and Accused CNA #2 on different dates rapidly undress Resident #16, who had moderate dementia, and that this would result in Resident #16 becoming upset and resistant to care. CNA #2 said that Accused CNA #1 and Accused CNA #2 told CNA #2 that they would intentionally upset Resident #16 so that Accused CNA #1 and Accused CNA #2 would not have to provide care. Review of CNA #2's written statement (undated) indicated that Accused CNA #1 and Accused CNA #2 would sometimes grab Resident #16 baby doll from Resident #16's arms to intentionally upset Resident #16, and then later joke about the incident. 5. CNA #2 said that from approximately early [DATE], to February 2011, CNA #2 observed Accused CNA #1 and Accused CNA #2 intentionally upsetting Resident #17. CNA #2 said that Accused CNA #1 and Accused CNA #2 told CNA #2 that they upset Resident #17 so that they would not have to provide incontinence care or transfer Resident #17. 6. CNA #2 said that, on an unspecified date, CNA #2 observed Accused CNA #3 tell Resident #18 (now deceased ) that Accused CNA #3 was Resident #18's "slave". CNA #2 said that Resident #18 was confused and delusional and believed that the Facility was Resident #18's personal home and the employees were servants. CNA #2 said that CNA #2 observed Accused CNA #3 tell Resident #18 "I'm your slave, what can I do for you?", or words to that effect. CNA #3 said that Accused CNA #3 spoke to Resident #18 in a mocking manner. Review of CNA #2's written statement (undated) indicated that Accused CNA #1 and Accused CNA #2 told CNA #2 that they did not like to provide care to Resident #18 because Resident #18 "was a [***] and does not deserve our time", or words to that effect. 7. Review of CNA #2's written statement indicated that Accused CNA #2 and Accused CNA #3 told CNA #2 that they did not provide care to Resident #19 because Resident #19 was unable to complain. 8. Review of CNA #2's written statement (undated) indicated that in late December, 2010, CNA #2 observed Accused CNA #2 in the dayroom dancing around Resident #20 and allowing Resident #20 to smack Accused CNA #2's buttocks while calling Resident #20 a "sexy dog", or words to that effect. CNA #2 indicated that Accused CNA #2 then laughed at Resident #20.

Based on record review and interviews, the Facility failed to prevent the abuse of 7 of 41 sampled residents (Residents #1, #2, #5, #6, #7, #10 and #17) by either Accused CNA #1, Accused CNA #2, Accused CNA #3 or Accused CNA #4 from approximately November 2010 to February 2011. Resident #1 and an unidentified resident were videotaped and pictures were disseminated on employees' cellular phones. Residents #2, #5, #6, #7, #10 and #17 were victims of repeated taunts, humiliation and curses which occurred in the presence of other staff members. The findings included: 1. Review of the Facility's report, dated 2/10/11, indicated that on 2/03/11 Facility staff informed management that an unidentified Certified Nursing Assistant (CNA) videotaped a female resident sitting, fully clothed, in a chair and that the resident responded to questions posed by the CNA. The report indicated that a staff member substantiated that in 2010, Accused CNA #1 showed another staff member a video of a resident on Accused CNA #1's cellular phone. Review of Resident #1's physical examination, dated 7/28/10, indicated that Resident #1 was disoriented to time and place and Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 was observed in the Facility at approximately 7:50 A.M.on 2/15/11. Resident #1 was not interviewed due to Resident #1's impaired cognition. Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/23/10, indicated that Resident #1 had impaired recall, had no behaviors, was non-ambulatory and required extensive assistance with bed mobility, transfers, toilet use. The MDS indicated Resident #1 was dependent on staff for bathing and personal hygiene. CNA #1 was interviewed at 8:50 A.M.on 3/14/11. CNA #1 said that in approximately March 2010, Accused CNA #1 told CNA #1 to watch a video Accused CNA #1 took of Resident #1 and that Resident #1 was "funny", or words to that effect. CNA #1 said that Accused CNA #1 showed CNA #1 a video on Accused CNA #1's cellular phone of Resident #1 sitting in a chair and fully dressed. CNA #1 said that, though the video did not show Accused CNA #1, CNA #1 heard the recorded voice of Accused CNA #1 asking Resident #1 questions and Resident #1 answering. CNA #1 said that Resident #1 was confused and disoriented. CNA #1 said that Accused CNA #1 asked Resident #1 if Resident #1 was "going to work tomorrow" (or words to that effect), what was the day of the week and other questions that Resident #1 was unable to answer accurately. CNA #1 said that Resident #1 answered Accused CNA #1's questions in a confused manner and that CNA #1 heard Accused CNA #1 laughing in response to Resident #1's answers. CNA #3 was interviewed at 1:09 P.M. on 3/17/11 and at 3:20 P.M. on 3/23/11. CNA #3 said that CNA #2 was working with Accused CNA #2 during an evening shift when Accused CNA #2 received a photograph on Accused CNA #2's cellular telephone. CNA #3 said that the picture was of a resident, who CNA #3 could not identify, seated on the toilet and not fully clothed. CNA #3 said that the unidentified resident appeared to be in the process of receiving care or using the toilet. CNA #3 said that Accused CNA #2 told CNA #3 that Accused CNA #4 was working at another facility (Facility #2), and Accused CNA #4 took the photograph of a resident of Facility #2, and sent it to Accused CNA #2. CNA #5 was interviewed at 4:00 P.M. on 3/23/11. CNA #5 said that Accused CNA #4 and CNA #5 worked together at Facility #2 during the beginning of December 2010. CNA #5 said that one evening Accused CNA #4 received a photograph on Accused CNA #4's cellular telephone. CNA #5 said that when Accused CNA #4 laughed, CNA #5 asked Accused CNA #4 what was funny and Accused CNA #4 told CNA #5 it was just a photograph. CNA #5 said that CNA #5 looked over the shoulder of Accused CNA #4 and observed a photograph of a person lying in a bed. CNA #5 said that the photograph appeared to be of a resident. CNA #5 said that CNA #5 did not recall anything specific regarding the photograph. CNA #5 said that Accused CNA #4 told CNA #5 that the photograph was sent to Accused CNA #4 by Accused CNA #1. CNA #5 said that approximately two weeks following the December 2010, incident with Accused CNA #4, CNA #5 and Accused CNA #4 worked together again. CNA #5 said that during the course of the evening, Accused CNA #4 told CNA #5 that the CNAs at the Facility took photographs of residents using their cellular telephones and sent them to each other. CNA #9 was interviewed at 5:00 P.M. on 3/22/11. CNA #9 said that, on more than one occasion, CNA #9 observed Accused CNA #1 taking photographs with Accused CNA #1's cellular telephone in residents' bedrooms. CNA #9 said that though CNA #9 did not know what was being photographed, residents were present in the room at the time the photographs were taken. The Surveyor observed Resident #1's bedroom on 2/15/11. Resident #1 was unable to be interviewed due to cognitive impairment. 2. Resident #2's annual MDS assessment, dated 11/4/10, indicated Resident #2 had impaired recall, was non-ambulatory, and was dependent on staff for all activities of daily living except eating. CNA #2 was interviewed at 1:39 P.M. on 3/17/11 and at 3:15 P.M. on 3/23/11. CNA #2 said that Accused CNA #3 was heard telling Resident #2 words to the effect of, "I [***] your husband every night and while he is [***] ing me, he tells me I am better in bed than you are" and "he (the husband) is leaving you", or words to that effect. CNA #3 was interviewed at 1:09 P.M. on 3/17/11 and at 3:20 P.M. on 3/23/11. CNA #3 said that Accused CNA #1 and Accused CNA #2 would be observed repeating back to Resident #2 the words that Resident #2 said out loud during care. CNA #3 said that it appeared that during times when Resident #2 was not agitated, the comments were made by Accused CNA #1 and Accused CNA #2 in an effort to cause Resident #2 to become agitated and cause the behaviors to escalate. CNA #4 was interviewed at 11:30 A.M. on 3/23/11. CNA #4 said Resident #2 was confused and often made sexual comments during personal care. CNA #4 said that, at times, Resident #2 would become agitated with personal care. CNA #4 said that Accused CNA #1 was heard and observed making fun of Resident #2 by referring to Resident #2's "dickie" (Resident #2's word for vagina) and saying "I am gonna [***] your dickie", or words to that effect. CNA #4 said that Accused CNA #2 was standing in the doorway and laughing at the scene. CNA #4 said that in response, Resident #2 would become agitated and more resistive to care and Accused CNA #2 would laugh even more. 3. Resident #5's quarterly MDS assessment, dated 3/10/11, indicated Resident #5 had impaired recall, was dependent upon staff for all activities of daily living except eating and was non-ambulatory. The MDS indicated Resident #5's [DIAGNOSES REDACTED]. Resident #5's care plan, initiated 12/16/10, indicated that Resident #5 had a history of [REDACTED]. CNA #1 said that Accused CNA #1 and Accused CNA #4 were observed to speak to Resident #5 in a mocking manner. CNA #1 said that when Resident #5 would say sexually inappropriate things to the staff, the Accused would encourage Resident #5 by repeating back to Resident #5 what Resident #5 had said. When asked how often this was observed, CNA #1 said that it appeared to be a routine occurrence, but CNA #1 was unable to provide any specifics regarding the number of times this was observed. CNA #3 said that Accused CNA #3 was heard asking Resident #5 about the penile implant and that Accused CNA #1 and Accused CNA #2 would encourage Resident #5 to "talk dirty and foul". CNA #3 was unable to elaborate as to the specifics of the conversations. CNA #4 said that Accused CNA #1 was heard on more than one occasion, during the fall and winter of 2010, asking Resident #5 to pump up Resident #5's penile implant. CNA #4 said that Resident #5 would respond in anger and yell and curse at Accused CNA #1 to stop, and that Accused CNA #1 would then laugh at Resident #5. Review of CNA #6's written statement, dated 2/08/11, indicated that CNA #6 observed Accused CNA #1 and Accused CNA #4 encourage Resident #5 to talk about Resident #5's penile implant and whether Resident #5's wife liked the implant. CNA #6 was interviewed at 2:05 PM on 3/22/10. CNA #6 said that Resident #5 was encouraged by Accused CNA #1 to talk about the implant and it was CNA #6's impression that this was done to instigate Resident #5 and at one point Resident #5 was asked whether Resident #5's wife liked it, or words to that effect and on another occasion Accused CNA #1 asked Resident #5 how the implant was used. CNA #10 was interviewed at 7:19 P.M. on 3/28/11. CNA #10 said that after the Accused CNAs were no longer working at the Facility, Accused CNA #1 told CNA #10 the reasons why Accused CNA #1 was no longer at the Facility. CNA #10 said that Accused CNA #1 admitted to "sexually harassing" two male residents, or words to that effect. CNA #10 said that Accused CNA #1 told CNA #10 that Accused CNA #1 would tell Resident #5 to pump up the penile implant because Accused CNA #1 wanted to "use it", or words to that effect. CNA #10 said that Accused CNA #1 told CNA #10 that Accused CNA #1 "just wanted to have fun" with Resident #5, or words to that effect. 4. Resident #6's quarterly MDS assessment, dated 11/4/10, indicated Resident #6 had impaired recall; had behavioral issues not directed toward others; was non-ambulatory; and was dependent on staff for all activities of daily living except eating. CNA #1 said Accused CNA #1 and Accused CNA #4 were observed speaking to Resident #6 in a mocking manner. CNA #1 said that Resident #6 was known to call out for assistance, such as "Nurse, Nurse, Nurse!", or words to that effect. CNA #1 said that Accused CNA #1 and Accused CNA #4 were observed and heard mimicking Resident #6 in Resident #6's presence. CNA #1 said that in response Resident #6 would become upset and the behavior worsened. CNA #1 said that in response, Accused CNA #1 and Accused CNA #4 laughed at Resident #6 in Resident #6's presence. CNA #2 said that on one occasion when Resident #6 was in bed and agitated and crying out, Accused CNA #3 entered the bedroom and walked past CNA #2. CNA #2 said that Accused CNA #3 told Resident #6 "your husband never loved you" and "your family never loved you and that is why you are here; and you are going to die here", and "We love (Resident #2) so much more than you. Nobody likes you ", or words to that effect. CNA #2 said that Accused CNA #1, Accused CNA #2 and Accused CNA #3 told Resident #6 that Resident #6 was "fat", or words to that effect. CNA #2 said that on one occasion Accused CNA #3 shoved a cookie in Resident #6's mouth and when Resident #6 coughed and spit the cookie out Accused CNA #3 called Resident #6 a "pig", or words to that effect. Review of CNA #2's written statement (undated) indicated that CNA #2 observed Accused CNA #1 and Accused CNA #2 tell Resident #6 that Resident #6 was "so annoying", "you're disgusting, you're covered in[***], or words to that effect. 5. Resident #7's annual MDS assessment, dated 9/30/10, indicated that Resident #7 had impaired short-term memory, intact recall, and some difficulty with daily decision-making. The assessment indicated that Resident #7 was dependent on staff for bed mobility, transfers, and was non-ambulatory. CNA #2 said that on one occasion Accused CNA #1 and Accused CNA #2 were in the bathroom providing care to Resident #7. CNA #2 said that CNA #2 remained outside the bathroom, but heard Accused CNA #1 and Accused CNA #2 telling Resident #7 they wanted Resident #7 to tell them about Resident #7's being a victim of spousal abuse. CNA #2 said that, initially, Resident #7 told Accused CNA #1 and Accused CNA #2 that Resident #7 preferred not to talk about the issue, but Accused CNA #1 and Accused CNA #2 repeatedly asked Resident #7 "tell me about how he used to beat you", or words to that effect. CNA #2 said that Accused CNA #1 and Accused CNA #2 offered to assist Resident #7 to recall the details of the alleged abuse. CNA #2 said that Resident #7 became tearful and begged Accused CNA #1 and Accused CNA #2 to stop their questions, but both Accused CNA #1 and Accused CNA #2 laughed openly at Resident #7. CNA #2 said that CNA #2 entered Resident #7's bathroom and told Accused CNA #1 and Accused CNA #2 to stop their behavior, but they told CNA #2 to get out of the room and slammed the door behind CNA #2. CNA #2 said that CNA #2 reported the incident to Nurse #6, who told CNA #2 that Nurse #6 did not believe CNA #2's report. CNA #2 said that Nurse #6 told CNA #2 that it was best for CNA #2 not to meddle in other people's business. 6. Review of CNA #2's written statement (undated) indicated that CNA #2 observed Accused CNA #3 tell Resident #10 that Resident #10's [MEDICAL CONDITION] bag smelled. CNA #2 indicated that Resident #10 became tearful and asked Accused CNA #3 for forgiveness. 7. Review of CNA #6's written statement, dated 2/08/11, indicated that CNA #6 observed Accused CNA #4 say that Accused CNA #4 would like to wash Resident #17's penis and then perform oral sex on Resident #17.