Every finding on record at Melrose Healthcare

Based on observation, record review and interview the facility failed to maintain a safe environment on two of two units. Specifically, the facility failed to maintain safe water temperatures in resident bathrooms. Findings include: On 3/17/26 at 3:52 P.M., the surveyor observed the following water temperatures in degrees Fahrenheit (F), in the first-floor bathrooms:102- 122.4 F101,103- 129.2 F104,106- 121.5 F108/110- 120.1 F 109/111- 120.5 F117/119- 128.2 F118/120- 126.5 F121/123- 127.9 F124/126- 135.1 F 122/124- 122.3 F On 3/17/26 at 4:25 P.M., the surveyor observed the following water temperatures in degrees Fahrenheit (F), in the second-floor bathrooms: 201/202- 129.4 F204/206- 132.5 F203/205 133.1 F212-133.6 F214/215- 132.0 F On 3/17/26 at 5:14 P.M., the surveyor and the Maintenance Director tested the water temperature in the bathroom of room [ROOM NUMBER]. The thermometer reading climbed above 130 degrees F. The Maintenance Director said that the temperature of the water should be between 110- and 120-degrees F. He said that the temperatures were above 120 degrees F in the morning when he tested the water and he adjusted the hot and cold-water mixing valve for the facility. The Maintenance Director said he did not re-check the temperatures after adjusting the water mixing valve. The Maintenance Director said that he checks the water temperatures weekly but could not produce any evidence of water temperature logs past 2/27/26. During a resident group meeting on 3/18/26 at 9:00 A.M., 5 out 11 residents said that the water in the bathroom was too hot. One resident said that he/she nearly burnt his/her hands when he/she went to wash their face. During an interview on 3/19/26 at 9:37 A.M., the Corporate Administrator said that water temperatures are not supposed to be above 120 F to prevent burns. He then said that when the mixing valve needs to be adjusted, the water temperatures should be retaken to ensure the adjustment of the mixing valve was effective. During an interview on 3/19/26 at 8:20 A.M., the Maintenance Director said that he was not able to locate a policy for obtaining and logging water temperatures in order to maintain water temperatures at a safe level.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that resident food was dated and not kept past the printed expiration dated in two of two unit refrigerators. Findings include:Review of the facility's policy titled Food Brought into Facility, revised September 2019, indicated, but was not limited to, the following:-Perishable foods must be stored and identified with resident's name, food item and use by date. These can be stored in the nursing unit kitchen nourishment refrigerator.-The nursing staff is responsible for discarding perishable foods on or before the use by date. On 3/17/26 at 7:19 A.M., the surveyor made the following observations in the first-floor unit Resident refrigerator:-A container of milk with a printed expiration date of 3/8/26.-An undated and opened container with two individual food items consistent in appearance with coconut macaroons; the container was missing a lid and the food was exposed to air.-An undated and unlabeled container of leftover prepared food in the freezer. On 3/17/26 at 7:23 A.M., the surveyor made the following observations in the second-floor Resident refrigerator:-Two sandwiches in an undated plastic bag which was open on one side.-A yogurt drink with a printed expiration date of 11/24/25.-A slice of food in an undated plastic bag, consistent in appearance with cake.-A container of milk with a printed expiration date of 3/16/26.-Five bagels in their original packaging with a printed date of 12/21/25.-A plastic bag containing a plastic container of leftover food; the plastic bag was labeled with a Resident name but there was no date on the outside of the bag, the inside of the bag, or on the plastic food container.-Individual packages of liquid protein with the following expiration dates: 1/8/26, 1/22/26, 3/4/26. During an interview on 3/18/26 at 11:28 A.M., the Food Service Director (FSD) said the food service and nursing staff manage the unit refrigerators. The FSD said her staff check the refrigerator daily for dates and anything expired or unlabeled. The FSD said anything expired or undated and/or unlabeled would be discarded. The FSD said that as the second-floor refrigerator was locked that food brought in by visitors was given to staff to be placed in the refrigerator; the FSD said she would expect staff to date and label the food before placing it into the refrigerator. The FSD said that nursing staff manages the liquid protein. During an interview on 3/20/26 at 9:05 A.M., the Director of Nursing (DON) said the dietary department manages the refrigerators and that staff would label and date food brought in by visitors and discard after three days. The DON said nurses should check the packets of liquid protein every day to make sure they weren't expired.

Based on observations and interviews, the facility failed to ensure a dignified dining experience on one out of two units. Specifically, on the second-floor unit, residents were served their meals on Styrofoam takeout containers, in Styrofoam cups, and with plastic utensils. Findings include:On 3/17/26 at 8:21 A.M., the surveyor observed breakfast being served to residents on the second-floor unit in Styrofoam take out style containers. The drinks were served in Styrofoam cups and plastic silverware was utilized by the residents. On 3/17/26 at 12:30 P.M., the surveyor observed lunch being served to residents on the second- floor unit in Styrofoam take out style containers. The drinks were served in Styrofoam cups and plastic silverware was utilized by the residents. On 3/18/26 at 8:11 A.M., the surveyor observed breakfast being served to residents on the second-floor unit in Styrofoam take out style containers. The drinks were served in Styrofoam cups and plastic silverware was utilized by the residents. On 3/18/26 at 12:13 P.M., the surveyor observed lunch being served to residents on the second-floor unit in Styrofoam take out style containers. The drinks were served in Styrofoam cups and plastic silverware was utilized by the residents. During an interview on 3/18/26 at 8:13 A.M., Certified Nurse Aide (CNA) #2 said that the facility has been utilizing Styrofoam for meal service on the second floor since the elevators went down back in January. She said the Styrofoam is lighter on the trays so the staff can carry them up and down the stairs. She said it was not home-like or dignified for the residents. On 3/18/26 at 8:14 A.M., the surveyor observed a sign on the elevator that indicated it had been out of service since 1/12/26. During an interview on 3/18/26 at 8:26 A.M., Resident #6 said that often times, meals were served cold because of the use of Styrofoam. Resident #6 said he/she is not sure why the food gets served to residents on the second floor that way because the residents on the first-floor unit get real plates, cups and silverware. He/she said it does not feel dignified to be served meals in that manner. During an interview on 3/18/26 at 8:32 A.M., Nurse #2 said that she is not sure why they are using Styrofoam and disposable dinner ware for the residents but that it has been since the elevator has been broke. She said it might be because it's easier to carry up the stairs from the kitchen. During resident group meeting on 3/18/26 at 10:00 A.M., 11 out of 11 participants said that prolonged eating off of Styrofoam to go containers is not homelike or dignified. During an interview on 3/18/26 at 10:50 A.M., the Administrator said the facility was utilizing disposable dishes because of the elevator and cleaning it all after meals would be a challenge. He said it was the Dietitian and food services who decided they were going to use Styrofoam for serving. He said that the Department of Public Health (DPH) was notified of the elevator issues and the entire facility plan including the use of Styrofoam for servicing meals to residents on the second floor. The surveyor requested a copy of the report, to include the use of Styrofoam for meals, but the Administrator did not provide it to the surveyor.During an interview on 3/18/26 at 11:05 A.M., the Registered Dietitian (RD) said that with the elevator being down food was being served in plastic take-out containers on the second floor so that the trays would be lighter to prevent spills and help with timeliness of tray passing. The decision was made for both staff convenience and to avoid spilling things and for the physicality of staff passing the trays in a timely manner. The RD said it was not ideal to serve food in plastic take-out container and that she would not consider it a homelike environment but that this was not a long-term solution. During an interview on 3/18/26 at 11:28 A.M., the Food Service Director (FSD) said that because the elevator was down the trays had to be taken upstairs which were too heavy and a burden for the staff; it was taking forever to get the trays to the second floor and things were getting spilled on the trays. The FSD said it was not homelike to serve each meal in plastic takeout containers. During an interview on 3/18/26 at 11:47 A.M., the RD said there was a discussion with the team regarding the elevator and the paper trays should be part of the submitted elevator plan. During an interview on 3/18/26 at 2:25 P.M., Family Member #1 said she was the activated health care proxy for a resident on the second- floor unit. She said that she was never informed of the plan to serve meals in Styrofoam containers to the residents of the second floor. She said that it was undignified for the residents to be served in this manner. During an interview on 3/19/26 at 7:51 A.M., the Director of Nurses (DON) said that serving residents meals on Styrofoam and with plastic silverware was not a homelike or dignified way to provide meals. She said this was part of the plan submitted to the DPH. She said it was also discussed with residents at Resident Council meetings At the time of the interview with the DON, the surveyor requested the report submitted to DPH indicating the use of Styrofoam for resident meals. The report was not provided. Review of Resident Council Minutes, dated 1/27/26 and 2/11/26, failed to indicate that the use of Styrofoam for meals was addressed with residents. During an interview on 3/19/26 at 9:53 A.M., the Activities Director said that during Resident Council meetings it was discussed that the elevator was out of service, but not that meals would be served on Styrofoam for residents as part of the plan. She said that it was not dignified for the residents receiving their meals on disposable paper goods.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Residents (#15 and #98), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #15, to implement contact precautions; and 2. For Resident #98, to ensure that the urinary catheter drainage bag was not placed directly on the floor. Findings include:1. Review of the facility's policy titled Infection Control Guidelines for Nursing Procedures, dated as revised 6/2024, indicated the following:-When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall:-Post the appropriate notice on the room entrance door so all personal is aware of precautions. [sic]-In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.-Examples of infections requiring Contact Precautions include but are not limited to: diarrhea associated with clostridium difficile. Resident #15 was admitted to the facility in September 2024 with diagnoses including noninfective gastroenteritis and colitis, urinary tract infection, adult failure to thrive, and insomnia. Review of Resident #15's most recent Minimum Data Set (MDS) assessment, dated 12/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. The MDS further indicated that the Resident required substantial/ maximal assistance for activities of daily living. Review of the Nurse Practitioner's progress note, dated 3/13/26, indicated the following:-Patient received empiric antibiotic including ceftriaxone/ Flagyl. Vancomycin was added with a high clinical suspicion for C. Difficile (a bacterium that causes diarrhea and colitis) colitis. Review of Physician's Orders indicated the following:-Maintain contact precautions due to pancolitis/ C-difficile, dated 3/9/26 and revised on 3/14/26.-Vancomycin (an antibiotic) 125 mg 1 capsule by mouth four times a day for pancolitis for 33 administrations, until finished, dated 3/9/26. Review of the March 2026 Medication Administration Record indicated that contact precautions had been maintained every shift beginning overnight on 3/13/26. Review of the Resident's active infection care plan, dated 3/14/26, indicated the following:-[Resident] has active infection and is being treated related to resident diagnosed of pancolitis/ c difficile, [sic] with interventions that included, Precautions: contact precautions. On 3/17/26 at 8:39 A.M., the surveyor observed a staff member transfer Resident #15 out of bed and into his/her wheelchair for breakfast. The staff member did not utilize any personal protective equipment (PPE) while transferring the Resident. There was no sign on the Resident's door indicating the need for contact precautions. On 3/18/26 at 6:37 A.M., the surveyor observed Resident #15 in his/her room. There was no sign on the Resident's door indicating the need for contact precautions. On 3/18/26 at 6:53 A.M., the surveyor observed a staff member assist Resident #15 out of bed and into his/her chair for breakfast. The staff member did not utilize PPE. The staff member brought the Resident to the dining room for breakfast. There was no sign on the Resident's door indicating the need for contact precautions. On 3/18/26 at 12:03 P.M., there was no sign on Resident #15's door indicating the need for contact precautions. On 3/19/26 at 7:19 A.M., there was no sign on Resident #15's door indicating the need for contact precautions. During an interview on 3/17/26 at 1:58 P.M., Certified Nurse Aide (CNA) #2 said they knew if a resident was on precautions if there is a sign on their room. The CNA said they would follow the signage on the door for PPE use. During an interview on 3/18/26 at 12:07 P.M., Nurse #2 said that Resident #15 was on contact precautions for C-difficile. The surveyor and Nurse #2 observed the Resident's room, and she said there was no signage indicating the need for contact precautions and there should have been. She said without the sign in place staff may not know about the need for PPE. During a follow up interview on 3/19/26 at 7:25 A.M., CNA #2 said that she was assigned to care for Resident #15 today. She said that she got him/her up and dressed and into his/her wheelchair. She said that he was not on any precautions and she did not utilize a gown when caring for the Resident today. She pointed to his/her room/doorway and said if he/she was on precautions there would be a sign on the door. During an interview on 3/19/26 at 7:54 A.M., the Director of Nurses (who was also the covering Infection Preventionist) said that Resident #15 was receiving antibiotics currently. She said there should be a sign on the Resident's doorway indicating contact precautions and staff should be implementing contact precautions as indicated in the Resident's physician's orders and care plan in order to prevent the spread of any potential infections. 2. Resident #98 was admitted to the facility in November 2022 with diagnoses that included osteomyelitis of the vertebra, dementia, acute and chronic respiratory failure with hypoxia, chronic kidney disease and anemia. Review of the MDS assessment, dated 3/8/26, failed to indicate a BIMS, and was assessed by staff as having moderate cognitive impairment. The MDS further indicated the use of an indwelling catheter. The MDS indicated that the Resident was dependent for activities of daily living. On 3/17/26 at 7:57 A.M., the surveyor observed Resident #98 in bed. The Resident had a Foley catheter, and the drainage bag was resting directly on the floor. The drainage bag was not maintained in a privacy bag. On 3/18/26 at 6:41 A.M., the surveyor observed Resident #98 in bed. The Resident had a Foley catheter, and the drainage bag was resting directly on the floor. The drainage bag was not maintained in a privacy bag. On 3/18/26 at 8:23 A.M., the surveyor observed Resident #98 awake in bed. The Resident's Foley catheter drainage bag was resting directly on the floor. The drainage bag was not maintained in a privacy bag. On 3/18/26 at 8:39 A.M., the surveyor observed two staff members assisting Resident #98 with a boost in bed in preparation for breakfast. The Resident's Foley catheter drainage bag remained in direct contact with the floor. The drainage bag was not maintained in a privacy bag. Review of Resident #98's active Physician's Orders indicated the following:-Foley catheter 16 Fr/(French) 10 ML (milliliter) continuous to drainage bag, dated 2/12/16. [sic].-Foley cath care every shift, dated 2/12/26. [sic].-Privacy bag for Foley cath drainage bag, dated 2/12/26. [sic]. Review of Resident #98's active care plan indicated the Resident had a Foley catheter due to retention with hydronephrosis, revised 12/20/25, and indicated a goal of, No complications associated with catheter use, incontinence. [sic] During an interview on 3/19/26 at 7:32 A.M., CNA #3 said that she had assisted in boosting Resident #98 in bed before breakfast yesterday. She said that when she was in the Resident's room the Foley drainage bag was on the floor, but it should not have been. She said the drainage bags should never be in direct contact with the floor. During an interview on 3/19/26 at 7:39 A.M., Nurse #1 said that Foley drainage bags should not be resting in direct contact with the floor. She said this would be an infection control concern. During an interview on 3/19/26 at 8:11 A.M., the Director of Nurses said that the Foley catheter drainage bag should not be resting on the floor because of infection control concerns. During an interview on 3/19/26 at 8:20 A.M., the Corporate Nurse said that the facility did not have a policy for catheter care.

Based on observation, record review, and interview, the facility failed to develop and implement the plan of care for one Resident (#35), out of a total sample of 23 residents. Specifically, the facility failed to incorporate the use of recommended front anti-tippers (used to prevent a person from tipping a wheelchair over) for the Resident's wheelchair. Findings include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as revised 1/2024, indicated that the resident comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. Resident #35 was admitted to the facility in October 2022 with diagnoses including Alzheimer's disease, stroke and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident #35 had severe cognitive impairment, scoring a 0 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #35 is dependent on staff for all activities of daily living. Review of the progress note, dated 3/4/26, indicated that Resident #35 was seen falling out of his/her wheelchair, landing on his/her face. Further review indicated that Resident #35 likes to roll back and forth in the wheelchair to self-sooth. Review of the Occupational Therapy (OT) note, dated 3/6/26, indicated a recommendation for front and back anti-tippers for the Resident's wheelchair. Review of the current care plan indicated a focus for Resident is at risk for falls. Further review failed to indicate an intervention for the use of anti-tippers on the wheelchair. On 3/17/26 at 8:13 A.M. and 10:35 A.M., the surveyor observed Resident #35 to be dressed, sitting in a wheelchair without front anti-tippers in place. On 3/18/26 at 8:25 A.M., the surveyor observed Resident #35 being fed in the hallway by Certified Nurse's Aide (CNA) #1. The surveyor also observed Resident #35 sitting in a wheelchair without front anti-tippers in place. On 3/18/26 at 10:00 A.M., the surveyor observed Resident #35 sitting in a wheelchair in the dining room with anti-tippers on the back of the wheelchair but not on the front of the wheelchair. The surveyor also observed the Maintenance Director attempting, unsuccessfully, to place anti-tippers on the front of the wheelchair. During an interview on 3/18/26 at 12:33 P.M., the Director of Nursing (DON) said that she expects the OT recommendations to be followed immediately and placed on the care plan. Review of the Purchase Order, dated 3/18/26, indicated an order for universal front anti-tippers. During an interview on 3/19/26 at 8:20 A.M., the Maintenance Director said that he had placed the order for the front anti-tippers on 3/18/26 (12 days after the recommendation to incorporate them for safety in the plan of care). The Maintenance Director said he wasn't sure when they would arrive.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#98), with pressure ulcers, received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 23 Residents. Specifically, for Resident #98, the facility failed to implement an order for an air mattress at the settings indicated in the physician's orders.Findings include:Resident #98 was admitted to the facility in November 2022 with diagnoses that included osteomyelitis of the vertebra, dementia, acute and chronic respiratory failure with hypoxia, chronic kidney disease and anemia. Review of the Minimum Data Set (MDS), dated [DATE], failed to indicate a Brief Interview for Mental Status, and was assessed by staff as having moderate cognitive impairment. The MDS further indicated the presence of one stage 4 pressure ulcer that was not present on admission to the facility. Review of physician's orders indicated the following:-Maintain resident on a pressure reducing mattress while in bed settings at 150 indicated for buttock wound, deconditioning and spinal osteomyelitis, dated 1/15/26. Review of the Resident's active care plan, dated as revised on 3/2/26, indicated the following:-Patient has actual skin found on admission. Pressure L (left) buttock. Found on admission of patient 1/14/25 Stage IV. Interventions included, put a low loss mattress on bed. Settings at 150. Review of the Norton Scale for Predicting Risk of Pressure Ulcers assessment, dated 3/13/26, indicated a risk score of 6, which indicated that the Resident was high risk for the development of pressure ulcers On 3/17/26 at 10:54 A.M., the surveyor observed Resident #98 in bed. An air mattress was in place and set at 100. On 3/17/26 at 4:50 P.M., the surveyor observed Resident #98 in bed. An air mattress was in place and set at 100. On 3/18/26 at 6:39 A.M., the surveyor observed Resident #98 in bed sleeping. An air mattress was in place and set at 100. On 3/18/26 at 8:05 A.M., the surveyor observed Resident #98 in bed sleeping. An air mattress was in place and set at 100. On 3/19/26 at 7:21 A.M., the surveyor observed Resident #98 in bed sleeping. An air mattress was in place and set at 100. During an interview on 3/19/26 at 7:34 A.M., Certified Nurse Aide (CNA) #3 said that the CNAs monitor the mattresses for accurate settings and if they think something is wrong, they will notify the nurse. She said, however, she was unsure of what Resident #98's mattress setting should be at. During an interview on 3/19/26 at 7:38 A.M., Nurse #1 said that resident's who use an air mattress have physician's orders that indicate the appropriate settings for use. She said that nurses will check the settings every shift to ensure the physician's order was implemented appropriately. She said someone should have noticed that Resident #98's air mattress was set incorrectly. During an interview on 3/19/26 at 8:08 A.M., the Director of Nurses said that Resident #98 had a pressure wound to his/her buttock and utilized an air mattress. She said air mattress orders were in place and nurses check every shift to ensure proper settings. She said Resident #98's air mattress should have been set as indicated in the physician's orders. She further said that the Resident may have lost weight, but if that was the case then the physician should have been updated and a new order obtained if indicated.

Based on record review and interviews, the facility failed to develop a person-centered Post-Traumatic Stress Disorder (PTSD) care plan for two Residents (#3 and #6), out of a sample of 23 residents. Specifically, the facility failed to identify potential triggers in order to eliminate or mitigate situations that may cause re-traumatization of the Resident. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as revised 10/2019, indicated that the policy is to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Further review indicated that nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Further review indicated that trauma informed care is culturally sensitive and person-centered. 1. Resident #3 was admitted to the facility in May 2024 with diagnoses including dementia, Parkinson's disease, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/08/26, indicated that Resident #3 is moderately cognitively impaired, scoring 10 out of 15 on the Brief Interview for Mental Status (BIMS) exam. Further review of the MDS indicated that Resident #3 requires assistance with all activities of daily living. Further review indicated that Resident #3 exhibited physical and verbal behaviors directed towards others four to six days a week. Review of the MDS assessment, dated 7/17/25, indicated that Resident #3 exhibited physical behaviors one to three days per week and verbal behaviors directed towards others four to six days a week. Further review indicated that the factors that can cause or exacerbate the behavior is the use of an alarm. Review of the Social Service progress note, dated 7/17/25, indicated that Resident #3 has trauma associated with his/her previous occupation. Review of the care plan indicated a focus of trauma informed care related to a prior traumatic event related to his/her previous occupation. Further review failed to indicate what the potential triggers were for re-traumatization or interventions to mitigate the effect of a trigger. During an interview on 3/19/26 at 7:40 A.M., the Corporate Nurse said that it is the facility's expectation that if a resident has a history of trauma that a care plan is developed that includes triggers for potential re-traumatization and any means of reducing the response to the trigger once it happens. The Corporate Nurse then said that the alarms sounding in the building could potentially be contributing to the Resident's behaviors. 2. Resident #6 was admitted to the facility in February 2026 with diagnoses that included unspecified peripheral vascular disease, type 2 diabetes, anemia, bipolar disorder, PTSD, and anemia. Review of Resident #6's MDS assessment, dated 3/2/26, indicated a BIMS score of 15 out of 15, indicating intact cognition. The MDS further indicated a diagnosis of PTSD. Review of Resident #6's active care plan, dated as revised on 3/11/26, indicated the following: -Focus: Trauma Informed Care: [Resident] has had a previous/recent traumatic event related to witnessing domestic abuse, experiencing physical/emotional/sexual abuse as a child, witnessing his/her sibling be sexually abused, sexual abuse while incarcerated. -Goal: [Resident] will have diminished risk for re-traumatization of past trauma through next review. -Interventions included but were not limited to: Determine best coping strategies that has worked in the past to help the resident cope with traumatic event. Refer the resident to psychiatric services for added psycho-social report. Refer the resident to support groups to assist in coping strategies. Further review of the Resident's PTSD care plan failed to indicate potential triggers for re-traumatization. Review of the Social Service evaluation, dated 2/25/26, indicated the following: -In section IV. Psychosocial Well Being/ Trauma Informed Care: -Psychiatric conditions and cognitive impairment -bipolar disorder -other: PTSD -Have you ever had an experience so upsetting that you think it changed you emotionally, spiritually, physically, or behaviorally? Answered as yes. -Do you think any of these problems bother you now? Answered as yes. -Would you be interested in discussing these problems? Answered as yes. Further review of the assessment failed to indicate potential triggers for re-traumatization were assessed. Review of Nursing notes failed to indicate any potential triggers for re- traumatization were assessed. During an interview on 3/19/26 at 8:12 A.M., the Director of Nursing said that potential triggers should be part of the Resident's plan of care to avoid a situation that may cause re-traumatization. She said staff caring for the Resident should be aware of his/her triggers. During an interview on 3/19/26 at 9:58 A.M., the Social Worker said that for residents with a diagnosis of PTSD, triggers should be documented to prevent re-traumatization. She said that if a resident was unable to express triggers, then that should be documented in the medical record. She said that she did not assess of any triggers for Resident #6, and that she would have to have a conversation with him/her to determine potential triggers.

Based on record review and interviews, the facility failed to ensure that medications were accurately implemented by nursing for one Resident (#11), out of a total sample of 23 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to accurately implement a Gradual Dose Reduction on an antipsychotic medication as recommended by Behavioral Health Services. Findings include: Resident #11 was admitted to the facility in May 2024 with diagnoses that included dementia, dysphagia, and anxiety disorder Review of Resident #11's Minimum Data Set (MDS) assessment, dated 1/29/26, indicated a Brief Interview for Mental Status score of 4 out of 15 indicating severe cognitive impairment. The MDS further indicated the use of antipsychotic medications on a routine daily basis. Further, the MDS indicated that a gradual dose reduction (GDR) was attempted on 1/24/26. Review of Resident #11's Psych Visit note, dated as 1/23/26, indicated the following:-Recommendations: With PCP (Primary Care Physician) approval recommend stopping Zyprexa 5 mg (milligrams) in the morning and start Zyprexa 2.5 mg in the morning x 7 days and stop. Please continue with Zyprexa 5 mg at HS (bedtime). Review of active, completed and discontinued physician's orders indicated the following:-Zyprexa 5 mg by mouth two times daily, dated as active 5/11/24 through 1/23/26.-Zyprexa (Olanzapine) 2.5 mg by mouth one time a day for 7 days, dated as active from 1/24/26 through 1/30/26.-Zyprexa 5 mg by mouth at bedtime, dated 1/31/26. Review of January 2026 Medication Administration Record (MAR) indicated that Zyprexa 5 mg was administered twice daily until 1/23/26. From 1/24/26 through 1/30/26 Zyprexa 2.5 mg was administered daily and then beginning 1/31/26 Zyprexa 5 mg was administered daily at bedtime. The MAR failed to indicate that Zyprexa 5 mg at bedtime was continued for the duration of the GDR as recommended by Behavioral Health Services. Review of the Consultant Pharmacist Recommendation to Nursing, dated 1/24/26, indicated the following:-New orders were written and the new orders state: Olanzapine 2.5 mg every morning x 7 days (1/24-1/31). Olanzapine 5 mg at bedtime to START 1/31/26 (when 2.5 mg stops).-This was not the psych recommendations and resident's behaviors may escalate given sudden decrease from 5 mg BID (twice daily) to 2.5 mg every morning and then back up to 5 mg at bedtime on the 31st. Please review and fix orders. Further review of the medical record failed to indicate a response to the Pharmacist's recommendation, and the recommendation was implemented incorrectly. During an interview on 3/19/26 at 7:41 A.M., Nurse #1 said that the psych Nurse Practitioner gives report to the nurses on her recommendations for the residents and then the nurses verify the orders with the physician or nurse practitioner in the facility. She said a second nurse or supervisor should double check all new orders to ensure they were implemented correctly. She said that orders implemented and administered incorrectly would be a medication error. She said that direct care staff were not involved in the monthly pharmacy recommendations and how they get implemented. During an interview on 3/19/26 at 8:00 A.M., the Director of Nurses said that she was aware that the GDR was not entered correctly. She said that the recommendation was confusing, but that it was not entered correctly based on the recommendation and it would be a medication error. During an interview on 3/19/26 at 9:50 A.M., the Psych Nurse Practitioner said that she was not aware that her recommendations were implemented incorrectly and said it would be a medication error. She said that some residents were more sensitive to changing doses on medications and when tapered too quickly there was potential for complications. During an interview on 3/19/26 at 10:44 A.M., Nurse Practitioner #1 said that she sees Resident #11 regularly in the facility. She said she recalled the GDR recommendation made by psych services for the Resident. The surveyor and the Nurse Practitioner reviewed the medical record together and she said that the recommendations were not implemented correctly, as recommended by psych. She said this was considered a medication error. She said that until now she was not made aware at any point that the recommendations had been entered incorrectly or that a medication error had occurred. Further, she said that she often signs off on pharmacist reviews but does not recall being made aware of the review for Resident #11 on 1/24/26 that indicated the recommendation was incorrectly implemented. She said reducing the dose of an antipsychotic medication too quickly has the potential to cause negative effects to the resident.

Based on observation, record review, and interview, the facility failed to ensure dental services were provided for one Resident (#43), out of a total sample of 23 residents. Specifically, the facility failed to facilitate the implementation of the dentist's recommendation for new dentures. Findings include:Review of the facility's policy titled Ancillary Physician Services, revised March 2025, indicated, but was not limited to, the following:-Social services or nursing representatives will assist residents with appointments, transportation arrangements, and for reimbursement of services under the state plan, if eligible. Resident #43 was admitted to the facility in November 2024 with diagnoses including type II diabetes and folate deficiency anemia. Review of Resident #43's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 10 out of 15, indicating moderate cognitive impairment. During an interview and observation on 3/18/26 at 9:58 A.M., Resident #43 said he/she needed teeth; the Resident said he/she had dentures a few years ago but had broken one set and lost the other before he/she was admitted to the facility. The Resident said he/she would like to have dentures as it would make it easier to bite his/her food but that he/she had not seen a dentist in the last year and that the facility had not yet scheduled an appointment with a dentist for him/her to receive dentures. The surveyor observed that the Resident was missing a majority of his/her teeth. Review of Resident #43's active Physician's Orders indicated the following order:-Consults: Audiology, Dental, Optometry or Ophthalmology, Podiatry, Psych services as needed, initiated 11/22/24. Review of Resident #43's most recent dentist evaluation, dated 3/10/25, indicated that Resident #43 had stated he/she had partial dentures but had lost one and broken another. The evaluation indicated that the Resident had stated he/she had difficulty chewing food and had requested dentures. The evaluation indicated the Resident would benefit from partial plate dentures, that the dentist recommended partial plate denture fabrication to restore the Resident's chewing and improve quality of life, and that the Registered Nurse was informed. Review of Resident #43's consent for dentures indicated, but was not limited to, the following:-I understand that dentures are medically necessary for me. The intended benefits of dentures are to help me maintain or improve my nutrition as well as tooth/gum and muscle balance. Dentures will also help restore my smile with a natural appearance.-I understand that if this treatment is delayed or is not performed, there may be risks to my oral and general health. These risks include, but are not, limited to, difficulty eating and maintaining proper nutrition, damage to gum tissue and mouth structures (such as TMJ - temporomandibular joint), shifting of any remaining teeth and deterioration in my facial muscles.Further review of the consent for dentures indicated that Resident #43's health care agent provided verbal consent to facility staff for the Resident to Receive dentures on 9/29/25. Review of the dental group schedule indicated the dentist's next visit to the facility was on 3/23/26 and that Resident #43 was not scheduled to be seen by the dentist. During an interview on 3/19/26 at 9:50 A.M., Certified Nursing Aide #4 said Resident #43 did not currently have dentures and that the Resident had missing teeth. During an interview on 3/18/26 at 3:34 P.M., Nurse #3 said when a Resident was seen by a dentist that nurses review the paperwork for recommendations and that when the dentist came to the facility, they communicated their recommendations verbally to the nurses. Nurse #3 said she was not sure if Resident #43 has ever had dentures or when the Resident was last seen by a dentist. During an interview on 3/28/26 at 4:00 P.M., the Medical Records staff said that the dentist sends a summary of their visits with recommendations to her and to the Director of Nursing (DON). The Medical Records staff said the dentist would also send a form to consent for dentures which then gets signed by the health care agent/representative and that she sends the signed consent back to the dentist. The Medical Records staff said that if she did not hear back for a month after sending the signed consent form that she would follow up with the dentist. The Medical Records staff said the dentist had originally asked for a consent in March of 2025 and that she had faxed a verbal consent to the dentist on 9/29/25 but that she had not followed up after that. The Medical Records staff said she was not sure why the dental visit for dentures was not implemented/scheduled, she said there was a number she could call to find out what happened but that she had not followed up. The Medical Records staff said the Resident had not refused to receive dentures, that refusals would be documented in the electronic medical record and that the last time the Resident was seen by a dentist was on 3/10/25. During an interview on 3/28/26 at 4:10 P.M., the DON said the dentist uploaded their visit summaries with recommendations in the Resident's electronic medical record which nurses review. The DON said that when dentists recommend dentures the dentist initiated the process and cross-checked with insurance for coverage; the DON said that if insurance would not cover the cost of the dentures that the facility would pay for them. The DON said Resident #43 had some missing teeth and that she did not think the Resident had dentures. The DON said the Resident had a consent for dentures. The DON said the Medical Records staff should have followed up with her and with the dentist after submitting the consent and not hearing back after a week but had not. During an interview on 3/19/26 at 11:56 A.M., the Corporate Nurse said that Resident #43 was apparently rejected for dentures by his/her insurance. The Corporate Nurse said the facility would pay for the dentures in that case and was not sure if the process of financing the dentures had started before now but that it should have been initiated before now. During an interview on 3/19/26 at 12:17 P.M., the MDS nurse said that the dentist had re-faxed an invoice for the dentures yesterday, which the dentist had originally sent to the facility in March of 2025. The MDS nurse said that the invoice was a result of the dentist running the insurance and finding out that the insurance did not cover Resident #43's dentures and that ideally the facility should have reviewed it and followed up. Review of Resident #43's re-submitted and unsigned invoice, dated 3/19/26, indicated the Resident had received a dental exam on 3/10/25 with a recommendation for denture fabrication as well as the following:-It is my understanding that [Facility Name] will be assuming financial responsibility for this plan of care. To move forward with this we need your written approval and payment. To approve this plan of care please sign and return this letter along with payment in the enclosed business reply envelope. During interviews on 3/20/26 at 12:40 P.M. and 12:55 P.M., the Administrator said the facility would cover the cost of a resident's dentures if the insurance did not and that facility staff should have followed up about Resident #43's dentures before now but had not.

Based on record review and interview, the facility failed to ensure the Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented in the medical record for one Resident (#98), out of a total sample of 23 residents. Specifically, for Resident #98, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently and accurately documented in the medical record.Findings include:Review of facility's policy titled Advance Directives, dated as revised 1/2024, indicated the following:-The plan of care of each resident will be consistent with his or her documented treatment preferences and/or advance directives.Resident #98 was admitted to the facility in November 2022 with diagnoses that included osteomyelitis of the vertebra, dementia, acute and chronic respiratory failure with hypoxia, chronic kidney disease and anemia. Review of the Minimum Data Set (MDS) assessment, dated 3/8/26, failed to indicate a Brief Interview for Mental Status, and the Resident was assessed by staff as having moderate cognitive impairment. Review of the Resident's MOLST form in the electronic medical record (EMR) indicated a form signed and dated 3/12/26 that indicated Do Not Resuscitate (DNR), Do Not Intubate (DNI), Transfer to Hospital. Review of active Physician's Orders indicated the following:-Full code, HCP (healthcare proxy) invoked due to end stage dementia, dated 9/11/25. Review of the Resident's active care plan, dated as revised 9/11/25, indicated the following:Advanced Directives: [Resident] has established advanced directives- Full Code Status. During an interview on 3/19/26 at 7:37 A.M., Nurse #1 said that when a MOLST form was updated or changed they then have to let the physician know so that they can sign it and update the physician's orders and plan of care for the Resident. She said advance directives should be documented consistently and accurately throughout the medical record. During an interview on 3/19/26 at 8:04 A.M., the Director of Nurses said that after the physician signs the MOLST form, orders should be implemented that reflect the resident's wishes on the MOLST form. She reviewed the Resident's medical record and said that the Resident's most recent MOLST indicated DNR/DNI, but the active physician's order was for a full code. She said that the Resident's wishes should be consistently and accurately documented in the medical record.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to implement multiple wound care treatment recommendations as recommended by the consultant Wound Physician Assistant (PA), including not implementing the recommended treatment type and/or at the recommended frequency, resulting in the deterioration of pressure ulcers and development of bilateral heel osteomyelitis (an infection of the bone). Findings include: Review of the facility policy titled 'Prevention and management of Pressure Ulcers/Injuries', revised November 2024, indicated: - If a new pressure ulcer is identified, assess the area and notify the provider for treatment order. Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred. Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital on 3/6/25 for bilateral heel osteomyelitis. On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. Resident #9's right heel was observed to be the size of a [NAME] with a red wound bed and the left heel was also approximately the size of a [NAME] with black and tan wound bed. During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes. During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer. During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not. Review of Resident #9's consultant Wound PA progress note, dated 1/6/25, indicated: - Left heel unstageable deep tissue injury (DTI) pressure ulcer: not improved. - Right heel unstageable deep tissue injury pressure ulcer: improved. - Plan: Left heel: Iodosorb (a wound care product, specifically a gel containing iodine, used to clean and promote healing in wet, chronic, or infected wounds) and DPD (dry protective dressing) (4x4 gauze) to the left heel wound changed daily and PRN (as needed). - Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN. Review of Resident #9's physician's order indicated: - DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA. - DTI right heel was implemented as recommended. Review of Resident #9's Treatment Administration Record (TAR), dated 1/8/25 to 1/12/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA). Review of Resident #9's consultant Wound PA progress note, dated 1/13/25, indicated: - Left heel unstageable deep tissue injury pressure ulcer: not improved. - Right heel unstageable necrosis pressure ulcer: not improved. - Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN. - Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN. Review of Resident #9's physician's order indicated: - DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA. - DTI right heel was implemented as recommended. Review of Resident #9's Treatment Administration Record (TAR), dated 1/13/25 to 1/19/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA. Review of Resident #9's consultant Wound PA progress note, dated 1/20/25, indicated: - Left heel unstageable necrosis pressure ulcer: not improved. - Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/13/25 from 1.6 cm (centimeters) length x 3.8 cm width x non-measurable depth to 2.0 cm length x 4.2 cm width x non-measurable depth. - Right heel unstageable necrosis pressure ulcer: improved. - Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN. - Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN. Review of Resident #9's physician's order indicated: - DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA. Review of Resident #9's Treatment Administration Record (TAR), dated 1/20/25 to 1/22/25, indicated the above order for the left heel was documented as implemented three times a day (once each shift) on 1/20/25 and 1/21/25, instead of once daily; and was documented as implemented twice daily (day and evening shift) on 1/22/25 (instead of once daily as recommended by the consultant Wound PA). Review of Resident #9's nursing progress note, dated 1/23/25, indicated: - R (right) heel warm to touch, malodorous, purulent (containing or producing pus) drainage, erythema. - New orders received for doxycycline (an antibiotic medication). - New wound care orders. wound dressing change bid (twice daily), may apply betadine(a topical antiseptic)/iodosorb cover with hydrofera blue (an antibacterial wound dressing). - Review of this note failed to indicate any changes in condition or changes to physician's orders to left heel wound treatment. Review of Resident #9's physician's order indicated: - DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA. - DTI right heel was implemented as ordered by the physician. Review of Resident #9's Treatment Administration Record (TAR), dated 1/23/25 to 1/26/25, indicated the above order for the left heel was documented as implemented two times (day and evening shift) each day (instead of once daily as recommended by the consultant Wound PA). Review of Resident #9's consultant Wound PA progress note, dated 1/27/25, indicated: - Left heel unstageable necrosis pressure ulcer: not improved. - Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/20/25 from 2.0 cm length x 4.2 cm width x non-measurable depth to 2.5 cm length x 5.0 cm width x non-measurable depth. - Right heel unstageable necrosis pressure ulcer: not improved. - Right heel unstageable necrosis pressure ulcer size increased from 1.4 cm length x 3.0 cm width x non-measurable depth to 2.0 cm length x 5.0 cm width x non-measurable depth. - Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN. - Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN. Review of Resident #9's physician's order indicated: - DTI left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled twice (day and evening shift) a day, instead of once daily as recommended by the consultant Wound PA. - DTI right heel (Twice Daily/prn) Cleanse with saline, apply bactroban followed by Alginate, skin prep to surroundings, DPD, initiated 1/29/25, scheduled twice daily (day and evening shift), instead of once daily as recommended by the consultant Wound PA. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's Treatment Administration Record (TAR), dated 1/27/25 to 2/2/25, indicated the above order for the left heel and right heel was documented as implemented two times each day (day and evening shift), instead of once daily as recommended by the consultant Wound PA. Review of Resident #9's Medication Administration Record (MAR), dated 1/27/25 to 2/2/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for right heel as recommended by the consultant Wound PA. During an interview on 4/8/25 at 10:56 A.M., Nurse #5 said she had put an additional order in for Iodosorb on 1/8/25 so it would be ordered from the pharmacy. Nurse #5 said that order should have been discontinued when the Wound PA recommended it to be discontinued but was not. Nurse #5 said since it was not, the iodosorb had been applied to heels since 1/8/25, even when it shouldn't have been. Review of Resident #9's consultant Wound PA progress note, dated 2/3/25, indicated: - Left heel unstageable necrosis pressure ulcer: improved. - Right heel unstageable necrosis pressure ulcer: not improved. - Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN. - Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN. Review of Resident #9's physician's order indicated: - DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep the surroundings, DPD/kling wrap, once daily (of note, this order also indicates twice daily), initiated 2/5/25. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's Medication Administration Record (MAR), dated 2/3/25 to 2/9/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's consultant Wound PA progress note, dated 2/10/25, indicated: - Recommend X-ray of the right heel to rule out osteomyelitis of the right heel. - Left heel arterial wound: improved. - Right heel arterial wound: not improved. - New right proximal heel arterial wound. - Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN. - Plan: Right heel: Iodosorb, DPD (4x4 gauze), and kling to right heel wound changed daily and PRN. - Plan: Right proximal heel: Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN. During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA was unable to say why her documentation for Resident #9's bilateral heels had changed from pressure ulcers to arterial ulcers, but that they were the same wounds. Review of Resident #9's physician's orders indicated: - Left heel wound treatment was implemented as recommended. - DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep surroundings, DPD/kling, once daily (of note, this order also indicates twice daily), initiated 2/5/25, instead of Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN which was not implemented as recommended by the consultant Wound PA until 2/18/25, eight days after it was recommended. - The orders failed to indicate the right proximal heel treatment recommendation for Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN. was ever implemented. Review of Resident #9's medical record failed to indicate any rationale for the right heel and right proximal heel treatments not being implemented as recommended by the consultant Wound PA. Review of Resident #9's consultant Wound PA progress note, dated 2/17/25, indicated: - Left heel arterial wound: not improved - Right heel arterial wound: not improved - Right heel arterial wound measurements increased in length and depth since last visit on 2/10/25 from 2.0 cm x 5.0 cm x non-measurable depth to 3.0 cm x 4.0 cm x 0.1 cm depth - Right proximal heel arterial wound healed. - Recommendations included for left and right heels were implemented as recommended. Right proximal heel was never discontinued because it had never been implemented after recommendation by consultant Wound PA 2/10/25. Review of Resident #9's nursing progress note, dated 2/19/25, indicated: - X-ray of right heel came in and was reviewed by NP #1, findings suspicious for calcaneal osteomyelitis, recommend MRI (a non-invasive imaging that visualizes soft tissues and bones in detail, aiding in the diagnosis and treatment of osteomyelitis). During an interview on 4/7/25 at 9:39 A.M., Nurse #6 said she booked the MRI for 3/4/25. Review of Resident #9's consultant Wound PA progress note, dated 2/24/25, indicated: - Recommend consult with PCP (primary care provider) for systemic antibiotic pending culture results. - Left heel arterial wound: not improved - Right heel arterial wound: not improved. There is bone exposed (which is a new finding). - New recurrent right proximal heel arterial wound present. - Plan: Left heel: Vashe (a type of wound cleanser) (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN. - Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD, and kling to the right heel wound changed twice daily and PRN. - Plan: Right proximal heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze) and kling to the right proximal heel wound changed daily and PRN. Review of Resident #9's physician's orders indicate: - DTI left heel implemented as recommended by consultant Wound PA on 2/27/25. - DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift), instead of twice daily as recommended by the consultant Wound PA, initiated 2/27/25. - DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice (day and evening shift) daily (instead of once daily as recommended by the consultant Wound PA), initiated 2/24/25. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25. Review of Resident #9's Treatment Administration Record (TAR), dated 2/24/25 through 2/26/25, indicated: - No wound treatment was documented to have been completed for left heel wound on 2/26/25. - No wound treatment was documented to have been completed for right heel wound on 2/26/25. - No wound treatment was documented to have been completed for right proximal heel wound on 2/25/25. Review of Resident #9's Medication Administration Record (MAR), dated 2/24/25 to 2/25/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25. Review of Resident #9's physician progress note, written by NP #1, dated 2/25/25, indicated: - XR (X-ray) right heel - findings suspicious for calcaneal osteomyelitis, recommend MRI. Wound examined today, overall worsening this week. Discussed with [consultant Wound PA] and agrees with proactive treatment. Will start rocephin 1g IM (intramuscular) pending wound culture results and toiler further IV antibiotics. MRI has been scheduled 3/4/25 at 8 A.M. Wound tx (treatment)- Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily. -This physician progress note does not include any changes to left heel wound treatment. Review of Resident #9's Treatment Administration Record (TAR), dated 2/26/25 to 3/3/25, indicated the following physician's order documented as implemented: - No wound treatment was documented to have been completed for right heel wound on 2/26/25. - DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (instead of twice daily as ordered by NP #1) from 2/27/25 to 3/3/25. Review of Resident #9's Medication Administration Record (MAR), dated 2/26/25 to 3/3/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA and NP #1), initiated 1/8/25. Review of Resident #9's nursing progress note, dated 3/1/25, indicated: - Continued on Amoxicillin (an antibiotic medication) 500-125 mg (milligrams) for bacterial infection. Also, he/she received Doxycycline 200 mg for wound infection. Review of Resident #9's nursing progress note, dated 3/3/25 at 12:08 P.M., indicated: - Resident's appointment [MRI] has been cancelled, may re-schedule if residents' health dictates. Review of Resident #9's consultant Wound PA progress note, dated 3/3/25 at 1:09 P.M., indicated: - Resident #9 is currently on antibiotics for wound infection. - X-ray results of the right heel noted findings suspicious for calcaneal osteomyelitis, recommend MRI. Per Nursing staff MRI is pending. - Wound culture of the right heel revealed moderate growth of mixed gram positive organisms consistent with normal skin flora. Moderate growth of multiple gram negative organisms. - Left heel arterial wound: Not improved. increased in size - Right heel arterial wound: Improved. There is bone is exposed. - Right proximal heel arterial wound: Not improved. Review of Resident #9's physician progress note, written by NP #1, dated 3/3/25 and time of visit undocumented, indicated: - Continues on augmentin, doxycycline for R (right) calcaneal osteo (osteomyelitis). - MRI has been scheduled for 3/4/25 at 8 am. - Wound tx (treatment)- Vashe, Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily. - This physician progress note does not include any changes to left heel wound treatment. Review of Resident #9's physician's order indicated: - DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift) (instead of twice daily as ordered by NP #1), initiated 2/24/25. Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/5/25, indicated the following physician's order documented as implemented: - DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (day shift) (instead of twice daily as ordered by NP #1) from 3/3/25 to 3/5/25. Review of Resident #9's physician's orders indicated: - DTI left heel implemented as recommended by consultant Wound PA on 3/3/25. - DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice daily (instead of once daily), initiated 2/24/25. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1. Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/6/25, indicated the above order for the right proximal heel was documented as implemented two times each day, instead of once daily as ordered by NP #1. Review of Resident #9's Medication Administration Record (MAR), dated 3/3/25 to 3/5/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1. Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital on 3/6/25 for bilateral heel osteomyelitis. Review of Resident #9's hospital discharge summary, dated 3/17/25, indicated: - Hospital Course: Bilateral heel wounds, necrotic, decubitus ulcers (pressure ulcers) with right heel osteomyelitis and left heel osteomyelitis. - Summary: Pt (patient) remains for medical management of bilateral heel wounds, necrotic, decubitus ulcer with MRI evidence of bilateral calcaneal osteomyelitis, receiving IV (intravenous) IVF (intravenous fluids) and IV abx (antibiotics). Review of Resident #9's medical record indicated he/she was readmitted to the facility 3/17/25. Review of Resident #9's nursing admission note, dated 3/17/25, indicated: - During his/her hospital stay MRI revealed R (right) heel osteomyelitis. - Wounds to BLE (bilateral lower extremities). Review of Resident #9's consultant Wound PA progress note, dated 3/24/25, indicated: - Left heel arterial ulcer: Improved. - Right heel arterial ulcer: Not improved. - Right proximal heel arterial ulcer appears healed. - Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN. - Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN. Review of Resident #9's physician's orders indicated: - Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily as recommended by the consultant Wound PA. - Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's Medication Administration Record (MAR), dated 3/24/25 to 3/30/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's record failed to indicate any rationale for initiation of adaptic in left heel treatment. Review of Resident #9's consultant Wound PA progress note, dated 3/31/25, indicated: - Left heel arterial ulcer: Improved. - Right heel arterial ulcer: Improved. - Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN. - Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN. Review of Resident #9's physician's orders indicated: - Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily as recommended by the consultant Wound PA. - Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's Medication Administration Record (MAR), dated 3/31/25 to 4/7/25, indicated the following order documented as implemented daily. - Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA. Review of Resident #9's Treatment Administration Record (TAR), dated 4/5/25 to 4/7/25, indicated: - Left heel: Cleanse with wound vashe, apply adaptic, alginate, DPD, and kling to left heel wound, once daily, initiated 4/2/25 and discontinued 4/5/25. - Left heel: Cleanse with wound vashe, apply iodosorb, DPD, kling to left heel wound, once daily, initiated 4/5/25. - Audit history of Left heel treatment order initiated 4/5/25 indicated it was input by the Director of Nursing (DON). Review of Resident #9's medical record failed to indicate any rationale for wound order change on 4/5/25. During an interview on 4/8/25 at 11:07 A.M., the DON said she did not contact the provider to obtain any orders to change the left heel wound treatment. The DON said she thinks it's because she saw iodosorb being used so she may have just added it. Review of Resident #9's consultant Wound PA progress note, dated 4/7/25, indicated: - Left heel arterial ulcer: not improved. - Left heel arterial wound measurements increased in length since last visit on 3/31/25 from 3.0 cm length x 3.7 cm width x non-measurable depth to 3.8 cm length x 3.7 cm width x 0.1 cm depth. - Right heel arterial ulcer: improved. During an interview on 4/7/25 at 9:03 A.M., Nurse #5 said the nurses on the floor are not usually involved in transcribing treatment recommendations from the consultant Wound PA. Nurse #5 said the DON is responsible for following up on consultant Wound PA recommendations. During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA said she expects physician's orders to be implemented according to her recommendations, unless the attending physician or nurse practitioner decline. She said she expects that they would address and document any rationale for the wound treatment recommendations not being implemented as she recommended based on the facility's policy. During an interview on 4/7/25 at 2:32 P.M., the Regional Nurse said the iodosorb that was initiated 1/8/25 was never discontinued but should have been multiple times. The Regional nurse said wound orders should be implemented and completed following the physician's order. During an interview on 4/8/25 at 8:55 A.M., Resident #9's Nurse Practitioner (NP) #1 said the consultant Wound PA sends her wound progress notes with recommendations to the facility and she expects the facility to implement them according to the consultant Wound PA's treatment recommendations. NP #1 said she rarely disagrees with the wound treatment recommendations and if she did, the rationale for not implementing should be documented in the record. NP #1 said she is rarely notified regarding wound orders, unless there is a significant concern. NP #1 says she expects the consultant Wound PA to manage the wounds and if the facility does not implement her recommendations as recommended it could cause a decline in the wound or wound infection. During an interview on 4/8/25 at 9:36 A.M., The DON said she expects wound treatment orders to be transcribed directly into the physician's orders according to the consultant Wound PA's treatment recommendations. The DON said every wound treatment recommendation should be implemented as recommended, and if for some reason it was not, the rationale should be documented in the medical record. During an interview on 4/11/25 at 11:08 A.M., the DON said wound treatment orders should be implemented at the frequency the physician orders. The DON said if a dressing is implemented too frequently or not frequently enough it puts the wound at risk for deterioration or infection. Refer to F726 and F880.

Based on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#20, #14, #88) out of a total sample of 23 residents. Specifically, 1. For Resident #20, the facility failed to develop a comprehensive pacemaker care plan. 2. For Resident #14, who was assessed to be at moderate risk for falls the facility failed to implement non-skid strips by his/her bed as per the plan of care. 3. For Resident #88, the facility failed to develop a personalized care plan with resident-specific interventions for suicidal indication history. 4. For Resident #88, the facility failed to develop and implement a personalized care plan for use of a hand orthotic as indicated by Occupational Therapy Findings include: 1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following: -1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification care upon admission: a. The name, address, and telephone number of the cardiologist. b. Type of pacemaker. c. Type of leads . d. Manufacturer and model. e. Serial Number. f. Date of implant; and g. Paced rate. -2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); 1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes. Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. During an interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker. Review of Resident #20's hospital discharge summary, dated 10/3/24, indicated AV block status post pacemaker 3/2022. The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25. Review of Resident #20's cardiac care plan, dated 10/6/24, indicated The Resident's Pacemaker information: Manufacturer: (SPECIFY) Model: (SPECIFY) Serial #: (SPECIFY) Date Implanted:(SPECIFY) Name of Cardiologist: (SPECIFY) Side of Chest: (SPECIFY) Pacemaker checked every year: (SPECIFY) via (SPECIFY). Pacemaker check as ordered. Review of Resident #20's physician note, dated 3/5/25, indicated AV block status post pacemaker. Review of Resident #20's physician orders failed to indicate orders relating to his/her pacemaker. During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #20 does have a pacemaker but she is not sure how it is monitored or any other details of the pacemaker. During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #20 does have a pacemaker and should have a comprehensive care plan in place with details of the pacemaker. 2. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she needed supervision/touching assistance for eating. Dependent on toileting hygiene and toileting. Review of Resident #14's fall care plan, dated 5/9/24, indicated Non-skid strips by the bed. On 4/6/25 at 8:20 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed. On 4/7/25 at 7:03 A.M., 8:18 A.M., 11:01 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed. Review of Resident #14's fall risk evaluation, dated 5/6/24, indicated he/she scored a 12 indicating moderate risk. During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #14 is a fall risk and tries to get out of bed at times. Nurse #4 said Resident #20's floor does not have non-skin strips. During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #14 is at risk for falls and his/her fall intervention of non-skid strips should be in place. 45984 3. Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Review of the facility policy titled Suicide Threats, revised and dated November 2017, indicated the following: - If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly. Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 6/6/24, indicated the following: - Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed. - Clinical Assessment: HX (history) Suicidality. Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 8/8/24, indicated the following: - HPI (History of Present Illness): Expresses passive SI - Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed. - Clinical Assessment: Passive SI reported to DON (Director of Nursing). HX Suicidality. Review of Resident #88's current active care plans failed to indicate that a care plan was developed indicating a history of Suicidal Ideations with individualized interventions or plans. During an interview on 4/7/25 at 1:55 P.M., the Social Worker said when residents are admitted to the facility we do an in-depth evaluation. The social worker continued to say a part of that evaluation is asking if the Resident has had any history or current suicidal ideations and if they have, an individualized care plan should be developed and implemented. The social worker said she was not aware of Resident #88's history of suicidal ideations. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said the facility should have developed a personalized care plan for Resident #88's history of suicidal ideation. 4. Resident #88 was admitted to the facility in May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident has upper extremity impairment on one side. Review of Resident #88's admission MDS dated [DATE] indicated that the Resident had upper extremity impairment on one side upon admission to the facility. During an observation on 4/6/25 at 8:26 A.M., Resident #88 was laying in his/her bed. The surveyor observed his/her right hand in a closed position. When asked if the Resident can flex open his/her right fingers, he/she was unable to open his/her right fingers. Resident #88 said his/her hands have always been like this, the Resident continued to say he/she does not remember seeing therapy recently and does not wear any device for his/her right hand. Review of Resident #88's current, discontinued, and completed physician's orders since he/she was admitted to the facility, failed to indicate an order for the use of a resting handing splint or for staff to ensure self range of motion exercises were implemented. Review of Resident #88's Occupational Therapy Evaluation and Plan of Treatment dated 5/23/24, indicated the following: - Fine Motor Coordination = Impaired (R hand impaired due to contracture of digits.) Review of Resident #88's Occupational Therapy Discharge Summary dated from 5/23/24 through 6/3/24, indicated the following: - Diagnosis: contracture, right hand, stiffness of right hand - Discharge Recommendations: Complete self-ROM (range of motion) on R hand daily. Use of R handed splint at night. The surveyor requested a policy on Occupational Therapy services for the facility, the facility said they do not have an Occupational Therapy policy. Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the Resident Care section: Provide active assistance ROM (range of motion)/strengthening/fine motor movement exercises as needed. Review of Resident #88's Activities of Daily Living care plan, dated 5/22/24, indicated the following interventions: - Provide active assistance ROM/strengthening/fine motor movement exercises as needed - Refer resident to OT/PT (occupational therapy/physical therapy) as needed Review of a physician's progress note dated 5/29/24 at 9:30 A.M., indicated the following: - Neuro patient does have contracture right hand, unable to extend all digits of the right hand. During an interview on 4/7/25 at 1:10 P.M., the interim Director of Rehab (DOR) said she is in the facility every day and she looks for range of motion changes if she is able. The DOR said the facility's OT is contracted out and is not here every day. The DOR then said the facility's sister buildings are more of a priory for therapy services due to insurance. The DOR then said for residents with range of motion impairments, they would ideally be seen by OT and Resident #88 was only seen last year due to a fall. The DOR said the Resident was admitted to the facility before she started working in the building and he/she should have been seen by OT to assess for range of motion impairments and progress. The DOR said she has only evaluated Resident #88 herself after he/she sustained a fall in the facility last year, not for his/her hand contracture. During an interview on 4/8/25 at 9:24 A.M., Nurse #8 said Resident #88's right hand has always been contracted and she has never seen him using a splint and she does not remember if he/she has ever been seen by therapy services. During an interview on 4/8/25 at 10:12 A.M., the Occupational Therapist (OT) said she has not personally evaluated Resident #88. The OT said Resident #88 has a right-hand contracture and he/she has a resting hand splint (a hand splint where the hand will lay flat to prevent the fingers from clenching), but he/she needs a better splint for his/her right hand. The OT said she did not complete the post-fall evaluation from last year on Resident 88, but clinically, if the Resident was able to use a resting hand splint, he/she would be able to fully stretch out his/her hand and now he/she cannot which indicates that it is a worsening contracture. The OT said she will be ordering Resident #88 a hand splint with a roll in it since his/her fingers are clenched. During a follow up interview on 4/8/25 at 10:46 A.M., the OT said she observed Resident #88's hand and she is ordering him/her a new splint with a roll in the fist as it is more appropriate for Resident #88's hand contracture. The OT then said Resident #88 was unable to fully extend his/her right hand upon her evaluation. During a follow-up interview on 4/8/25 at 11:15 A.M., Resident #88 said he/she has a hand splint in his/her bedside table drawer. Resident #88 proceeded to dig to the bottom of the drawer to pull out a hand splint in a bag which had many belongings on top of it. He/she said it is too uncomfortable, and he/she does not wear it. Resident #88 said he/she does not remember staff members ever coming in to stretch out his/her hand. During an interview on 4/8/25 at 11:25 A.M., Certified Nursing Assistant #8 said she has worked in the facility for over [AGE] years. CNA #8 said she did not know the Resident has a hand contracture and has never stretched out his/her hands for range of motion. CNA #8 continued to say she has never seen a hand splint for Resident #88. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said Resident #88's interventions from his/her OT Discharge summary should have been followed, he/she should have had his hand stretched out daily and he/she should have been using a hand splint. The DON said there should have been physician's orders in place for these so they can be implemented. The DON said she is not sure how staff can monitor these interventions if there are no physician's orders in for them. During an interview on 4/9/25 at 10:11 A.M., the Medical Director said the resting hand splint was too uncomfortable for Resident #88. The MD said he would expect staff to encourage him/her to wear it and stretch out his/her hand as able. The MD then said he thinks Resident #88 would have benefited from more therapy services.

Based on observations, record review, and interviews, the facility failed to provide a dignified dining experience for the residents of the facility as well as provide a dignified existence for four Residents (# 52, #14, #57 and #13), out of a total sample of 23 residents. Specifically, the facility failed to: 1) provide a dignified dining experience to the residents on the first and second floor, 2) provide privacy during care for Resident #52, 3) provide dignity while providing incontinence care by using double incontinence briefs for Residents #52, #14 and #57 and 4) provide a dignified environment for Resident #13. Findings include: Review of the facility policy titled, :Resident Rights, dated 1/24, indicated the following: -Employees shall treat all residents with kindness, respect and dignity. a. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence b. be treated with respect, kindness, and dignity t. privacy and confidentiality. 1. The facility failed to provide a dignified dining experience to the residents on the first and second floor. The following was observed on the first floor unit during the days of survey: - On 4/6/25 at 8:37 A.M., a staff member was observed feeding a resident who was lying in bed while standing over them, not at eye level. - On 4/6/25 at 12:38 P.M., a Certified Nursing Assistant (CNA) was overheard saying is he a feed while passing out lunch trays with other residents nearby. - On 4/7/25 at 8:13 A.M., a staff member was observed standing over a resident feeding him/her breakfast while he/she was laying in his bed. - On 4/8/25 at 12:34 P.M., a CNA was overheard saying is he a feeder while passing out lunch trays with other residents nearby. On 4/6/25 at 8:34 A.M., and 8:38 A.M., staff were overheard referring to residents as feeds in the presence of residents when passing out breakfast trays on the second floor. The following was observed in the second-floor dining room during lunch on 4/6/25: -Three residents were seated at a dining table. The first resident was served lunch at 12:24 P.M. The other two residents were served lunch at 12:40 P.M. and 12:42 P.M., 16-18 minutes later. - Three residents were seated at a dining table. The first resident was served lunch at 12:24 P.M. The other two residents were served lunch at 12:40 P.M. and 12:42 P.M., 16-18 minutes later. -Three residents were seated at a dining table. The first resident was served lunch at 12:35 P.M. The last resident was served lunch at 12:53 P.M., 18 minutes later. -Three residents were seated at a dining table. The first resident was served lunch at 12:25 P.M. The last resident was served lunch at 12:52 P.M., 27 minutes later. -At 12:35 P.M., two staff were overheard referring to residents as feeds in the presence of residents when passing out lunch trays. The following was observed in the second-floor dining room during breakfast on 4/7/25: -Three residents were seated at a dining table. The first resident was served breakfast at 7:56 A.M. The last resident was served lunch at 8:09 A.M., 13 minutes later. -Two residents were seated at a table. The first resident was served breakfast at 7:57 A.M. The second was served at 8:11 A.M., 14 minutes later. -Two residents were seated at a table. The first resident was served breakfast at 7:57 A.M. The second was served at 8:07 A.M., 10 minutes later. The following was observed in the second-floor dining room during lunch on 4/7/25: -Three resident were seated at a dining table. The first resident was served lunch at 12:28 P.M. The last resident was served lunch at 12:39 P.M., 11 minutes later. -Three resident were seated at a dining table. The first resident was served lunch at 12:27 P.M. The last resident was served lunch at 12:45 P.M., 18 minutes later. -Three resident were seated at a dining table. The first resident was served lunch at 12:34 P.M. The last resident was served lunch at 12:48 P.M., 14 minutes later. On 4/8/25 at 8:37 A.M., two staff on the second floor were overheard referring to residents as feeders in the presence of residents when passing out breakfast trays. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said the staff are expected to provide a dignified dining experience for the residents of the facility. The Director of Nursing said staff should be at eye level with residents while assisting them with a meal, should not refer to residents with labels such as feeds or feeders and all residents who are seated at the same table should be served meals at the same time. 2. The facility failed to provide privacy during care for Resident #52. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks. On 4/6/25 at 8:19 A.M., a staff member was toileting and changing Resident #52's incontinence brief in a hallway bathroom with the door open, visible to anyone walking by. During an interview on 4/9/25 at approximately 11:30 A.M., Certified Nursing Assistant #3 said privacy should be ensure while providing any personal care by pulling the privacy curtain or closing the door. 3. The facility failed to provide dignity while providing incontinence care by using double incontinence briefs for Residents #52, #14 and #57. a. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks. On 4/8/25 at 11:32 A.M., Resident #52 was observed to be wearing two incontinence briefs at the same time. During an interview on 4/8/25 at 11:35 A.M., Certified Nursing Assistant (CNA) #3 said he assisted the Resident with his/her morning care, and he placed two incontinence briefs on the Resident to ensure they would stay in place. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified. 43846 b. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she was dependent on staff for toileting tasks. On 4/8/25 at 11:39 A.M., Resident #14 was observed to be wearing two incontinence briefs at the same time. During an interview on 4/8/25 at 11:39 A.M., Certified Nursing Assistant (CNA) #5 said the 11:00 P.M. to 7:00 A.M. shift did his/her morning care. CNA #5 said staff should not be double briefing residents but Resident #14 does have two incontinence briefs on. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified. c. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder (PTSD), dementia, frontotemporal neurocognitive disorder, and depression. Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated he/she scored a 00 out of 15 on the BIMS indicating sever cognitive impairments. The MDS also indicated Resident #57 is dependent on staff for toileting tasks. On 4/8/25 at 11:43 A.M., Resident #57 was observed to be wearing two incontinence briefs at the same time. During an interview on 4/8/25 at 11:43 A.M., Certified Nursing Assistant #2 said she assisted the Resident with his/her morning care, and she placed two incontinence briefs on the Resident to ensure they would stay in place. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified. 45984 4. Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure. Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. The surveyor made the following observations: - On 4/6/25 at 10:50 A.M. and on 4/7/25 at 1:22 P.M., a cork board beside Resident #13's bed was observed to say Fuck this place written in pen. During an interview on 4/6/25 at 10:50 A.M., Resident #13 said he/she did not write that, it was in the room when he/she moved in and he/she does not like it there. During an interview on 4/8/25 at 9:02 A.M., Nurse #8 said that should not be written in his/her room and it needs to be removed. Nurse #8 said Resident #13 moved into the room not long ago and it was written by the previous resident. Nurse #8 said it should have been removed before Resident #13 moved into the room. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said that the derogatory language should not be written in Resident #13 room, and all residents should have a dignified experience in the facility.

Based on observation and interview, the facility failed to maintain a home-like environment. Specifically, 1. The facility failed to ensure that the second floor was free from odors. 2. For Resident #80, the facility failed to ensure the resident's room did not smell of urine and was free from small black flying insects. 3. For Resident #52, the facility failed to ensure his/her mattress was intact without any missing fabric. Findings include: The facility was unable to provide a home-like environment policy. 1. On 4/6/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (7:00 A.M. - 3:00 P.M.) On 4/7/25 and 4/8/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (6:45 A.M. - 3:00 P.M.) During an interview on 4/6/25 at 12:40 P.M., Family member #1 said she comes on different days and different times during the week and the second floor always has a bad smell which is not great for her or the residents. During the resident group meeting conducted on 4/7/25, 14 out of 16 participating residents complained about the odor of the facility and that there is always a constant bad odor. During an interview on 4/9/25 at 10:02 A.M., the Activities Director said it has a bad odor on the second floor of the facility at all times. During an interview on 4/9/25 at 11:13 A.M., the Administrator said he has noticed a smell on the second floor and it is because a resident's foley catheter has leaked into the floor and gotten under the tiles. He said housekeeping does their best to eliminate the odor. 48990 2. Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 4/6/25 at 7:28 A.M., Resident #80 approached the surveyor in the hallway and said he/she is disgusted with their room because it constantly smells strongly of urine. Resident #80 said it's so bad he/she needs to open the window frequently to help lessen the smell of urine. Resident #80 said he/she spends very little time in the room because of the smell. Resident #80 said he/she has told many staff members about the smell, but nobody does anything about it. Resident #80 further said he/she has expressed concern about cockroaches in the room because staff does not remove old food from the room. On 4/6/25 at 7:43 A.M, the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag of soiled briefs visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying insects throughout the room. On 4/6/25 at 12:12 P.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were greater than ten small black flying bugs throughout the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. A certified nurse assistant (CNA) delivered a meal tray to Resident #80's roommate and swatted her hand as she walked through the small black flying insects. On 4/7/25 at 8:45 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room. 0n 4/8/25 at 9:14 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room. During an interview on 4/7/25 at 8:48 A.M., CNA #7 said Resident #80 often opens the window, but said she was unsure why. CNA #7 said Resident #80 complains about bugs being in the room, specifically cockroaches, but that she hasn't seen any bugs herself and thinks it's not true. During an interview on 4/9/25 at 8:18 A.M., the Director of Nursing (DON) and Regional Nurse said staff should attempt to remove wrappers, food, and trash from Resident #80's room. They said yesterday they removed more than 20 juice containers from his/her room and those probably attracted the small black flying insects. They further said if there is an odor of urine present staff should identify and remove the source of scent if possible, and if unable to identify the source, then housekeeping should be notified because it might be in the mattress or somewhere that needs to be cleaned. 41456 3. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks. On 4/8/25 at 7:18 A.M., the surveyor observed Resident #52's unmade bed. The mattress had a hole in the top layer of material throughout the middle of the mattress with dark brown stains throughout the mattress. During an interview on 4/8/24 at 2:12 P.M., the Director of Nursing looked at a picture of Resident #52's mattress and said that the mattress should not have any missing layer of fabric and should be replaced. The Director of Nursing said the maintenance department usually inspects all mattresses and if there is damage to a mattress it will be replaced.

Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for two Residents (#70 and #4) out of a total sample of 23 residents. Specifically, 1. For Residents #70, who is at risk for developing pressure ulcers, the facility failed to ensure his/her air mattress was set according to the physician's order. 2. For Resident #4, the facility failed to follow a physician's order to obtain a Urine Analysis in a timely manner. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease. Review of Resident #70's most recent Minimum Data Set (MDS) assessment, dated 3/13/25, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers. On 4/6/25 at 8:05 A.M. and 12:34 P.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs (pounds). On 4/7/25 at 7:05 A.M., 8:20 A.M., and 11:01 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs. On 4/8/25 at 7:41 A.M. and 10:24 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs. Review of Resident #70's physician order, dated 2/20/24, indicated Low air loss mattress setting 150. Review of Resident #70's last weight taken was on 3/2/25 and was 136.5 lbs. Review of Resident #70's Norton Scale (scale for predicting risk of pressure ulcers), dated 3/7/25, indicated he/she scored a 6 indicating high risk for developing pressure ulcers. On 4/8/25 at 11:45 A.M., the surveyor with Nurse #4 observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs. Nurse #4 said the air mattress should be set to 150 per the doctor's order. Nurse #4 said the Resident is on an air mattress because he/she is at risk for skin breakdown. During an interview on 4/8/25 at 2:14 P.M., the Director of Nursing said Resident #70 is at risk for developing pressure ulcers and his/her air mattress should be set per the physician's order. 45984 2. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy. Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Review of Resident #4's physician's orders indicated the following order dated 4/1/25: - Obtain UA (urine analysis) C&S (culture and sensitivity) r/o (rule out) jaundice, every shift may d/c (discontinue) when obtained. During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said the Nurse Practitioner came in to see Resident 4 and she said that he/she looked yellow, so she wanted to obtain a urine sample to rule out Jaundice. Nurse #7 then said Resident #4 every time staff take Resident #4 to the bathroom they should attempt to collect a urine sample. Nurse #7 said this should have been followed up on sooner, 100%. During an interview on 4/8/25 at 10:27 A.M., Nurse Practitioner (NP) #2 review Resident #4's physician's orders with the surveyor, NP #2 said she was not sure why the order was put in to rule out jaundice as she never mentioned that. NP #2 said when she evaluated Resident #4, he/she pointed to his/her abdomen indicating discomfort, so she wanted to collect a urine sample to get more information. Nurse Practitioner #2 said a urine analysis should be obtained within 24 hours. Review of the Laboratory binder on the first floor B-side nursing station indicated a laboratory requisition form for Resident #4's urine to be obtained. The Form indicated that urine was collected on 4/6/25 but it was not picked up by laboratory for analysis. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said when an order for a urine analysis is put in, the urine should be obtained within 24 hours. The DON reviewed the lab requisition form and she said this is the form that is supposed to go with the urine sample when sent out to the lab and she was not sure why the sample was not sent out.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for seven Residents (#14, #57, #52, #57, #70, #34, #48 and #4) out of a total sample of 23 residents. Specifically, 1. For Residents #14, #57 and #52, the facility failed to provide incontinent care; and 2. For Residents #57, #70, #34, #48 and #4, the facility failed to provide assistance with meals. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/24, indicated the following: -Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Elimination (toileting); d. Dining (meals and snacks). 1a. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she needed supervision/touching assistance for eating. The MDS also indicated Resident #14 is dependent on staff for toileting tasks and is always incontinent of urine and frequently incontinent of bowel. On 4/7/25 at 8:25 A.M., Resident #14 was observed in bed being assisted with his/her breakfast. From 8:25 A.M. to 1:00 P.M., Resident #14 was observed in his/her room and was not observed to have staff offer to toilet him/her or have incontinent care provided. On 4/8/25 from 7:27 A.M. to 11:35 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided. Review of Resident #14's incontinence care plan, dated 11/1/24, indicated incontinent: check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Apply clean clothes and change clothing PRN after incontinence episodes. Review of Resident #14's potential skin care plan, dated 11/1/24, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Review of Resident #14's nursing summary, dated 3/21/25, indicated - Bathing: dependent. - Continence: 3. Incontinent of both bowel and bladder. During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours. During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours. During an interview on 4/8/25 at 11:27 A.M., CNA #5 said Resident #14 is on her assignment to provide care to and that the 11:00 P.M to 7:00 A.M. staff gave Resident #14 his/her morning care. CNA #5 said Resident #14 has been up in the dining room since she started her shift and 7:00 A.M. and has not provided him/her with any incontinence care yet. On 4/8/25 at 11:39 A.M., the surveyor with CNA #3 observed Resident #14's incontinence brief it was heavily soaked with urine. During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours. 1b. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression. Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she was dependent for toileting tasks and is frequently incontinent of both bowel and bladder. On 4/7/25 at 8:30 A.M., Resident #14 was observed in the dining room eating breakfast. From 8:30 A.M. to 1:34 P.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided. On 4/8/25 from 7:27 A.M. to 11:33 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided. Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Toilet use: assist Review of Resident #57's incontinence care plan, dated 11/13/24, indicated Incontinent: Check every 2-3 hours and as required for incontinence. Review of Resident #57's potential skin care plan, dated 4/1/25, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours. During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours. During an interview on 4/8/25 at 11:33 A.M., CNA #2 said she gave Resident #14 care around 7:00 A.M. today and has not provided incontinent care again today. CNA #2 said Resident #14 is always incontinent and should be changed every two hours but was not. On 4/8/25 at 11:43 A.M., the surveyor with CNA #2 observed Resident #14's incontinence brief it was heavily soaked with urine. CNA #2 said urine leaked out onto Resident #14's pants and they needed to be changed. During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours. 1c. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks. On 4/7/25 at 8:30 A.M., Resident #52 was observed in the dining room eating breakfast. From 8:30 A.M. to 12:54 P.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided. On 4/8/25 from 7:30 A.M. to 11:32 A.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinence care provided. Review of Resident #52's incontinence care plan, last revised 4/7/25, indicated the following interventions: -Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Review of Resident #52's Activity of Daily Living care plan, last revised 4/7/25, indicated the following interventions: -Toilet use: dependent. -Incontinent bowel and bladder. Review of Resident #52's potential for skin impairment care plan, last revised 10/14/24, indicated the following interventions: -Toileting assistance on toileting schedule or routine, -Protect skin with incontinent care. Review of the nursing summary dated 3/19/25, indicated Resident #52 is incontinent of both bowel and bladder. Review of Resident #52's Kardex (a form indicating the level of assistance needed for daily care) indicated the following: -Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours. During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours. During an interview on 4/8/25 at 11:32 A.M., CNA #3 said he provided Resident #52's morning care before breakfast. CNA #3 said all residents who are incontinent should be checked and/or changed every 2 hours, however, he had not checked or toileted Resident #52 since this morning, 4 hours ago. During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours. 2a. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression. Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she requires partial/moderate assistance from nursing staff for eating. On 4/6/25 from 12:36 P.M. to 12:38 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident. On 4/7/25 from 12:40 P.M. to 12:49 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding, playing with his/her food. No staff were assisting the Resident. On 4/8/25 from 8:39 A.M. to 8:45 A.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident. During an interview on 4/6/25 at 12:40 P.M., Family member #1 said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her meal. Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Eating: supervision/cues to assist. Review of Resident #57's nutrition assessment, dated 3/26/25, indicated Dining assistance: Total Dependence. During an interview on 4/8/25 at 9:21 A.M., CNA #2 said Resident #57 needs assistance with his/her meals and staff are suppose to sit and assist them once the Resident receives his/her meal. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed. 2b. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease. Review of Resident #70's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated the Resident needs supervision/touching assistance from staff for eating. On 4/6/25 at 8:35 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room. On 4/7/25 from 8:19 A.M. to 8:30 A.M., the surveyor observed Resident #70 in bed with his/her breakfast tray on his/her tray table next to their bed not set up the Resident was observed to struggle to open his/her butter packets. No staff were present in the room. On 4/7/25 from 12:44 P.M. to 12:47 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room. On 4/8/25 from 8:40 A.M. to 8:48 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room. On 4/8/25 from 12:55 P.M. to 12:59 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room. Review of Resident #70's activities of daily living, dated 5/21/24, indicated eating: set up, encourage and assist as needed. Review of Resident #70's active Kardex (a form indicating the level of care needed) indicated eating: set up, encourage and assist as needed. Review of Resident #70's nutrition therapy assessment, dated 3/10/25, indicated Dining Assistance: Independent, Supervision. Legal blindness. Review of Resident #70's nursing assessment, dated 3/19/25, indicated the Resident was blind. Eating: continual supervision (ratio 1:8) Dysfunction: 1. Unable to sequence task/follow simple directions.3. Easily fatigued. 10. Decreased ROM (Range of Motion). 11. Generalized weakness. Review of Resident #60's ADL flow sheet for 4/6/25 he/she was coded as dependent on staff for eating. On 4/7/25 he/he was coded as supervised for eating. On 4/8/25 for breakfast and lunch coded as supervised. During an interview on 4/8/25 at 12:05 P.M., CNA #4 said she takes care of Resident #70 regularly but does not supervise him/her or assist them with their meals. CNA #4 said that staff should be following the Resident's Kardex and care plan. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed. The DON said the Resident likes their meal left but staff should be setting up his/her meal tray. 41456 2c. Resident #34 was admitted to the facility in February 2024 with diagnoses including hemiplegia. Review of Resident #34's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (MDS) which indicated he/she is cognitively intact. The MDS also indicated Resident #34 required partial to moderate assistance for self-feeding tasks. On 4/6/25 at 8:14 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway. On 4/6/25 at 12:45 P.M., Resident #34 was observed eating lunch at a table at the end of the second-floor unit hallway. There were no staff at that end of the hallway and the Resident was not visible from the nursing station. From 12:45 P.M., to 12:59 P.M., the Resident was observed staring at his/her lunch and not eating. On 4/7/25 at 8:17 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway. On 4/8/25 at 8:26 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway. Review of Resident #34's Activity of Daily Living care plan, last revised 3/6/35, indicated the following: -Eating: assist to dependent. -Self performance may vary depending on cognition, behavioral symptoms and activity tolerance. -Explain all procedures and purpose prior to performing task and encourage self-performance. Review of Resident #34's Kardex (a form indicating the level of care needed for self-care tasks) indicated the following: -Eating: assist to dependent. Review of the nursing summary dated 3/21/25, indicated Resident #34 was dependent on staff for self-feeding tasks. During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #34 requires assistance with meals at times and when not needing assistance, the Resident definitely needs cueing from staff to continue with the task. During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #34 does not always require physical assistance with meals and sometimes just requires supervision. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat. 2d. Resident #48 was admitted to the facility in September 2024 with diagnoses including Alzheimer's Disease and failure to thrive. Review of Resident #48's most recent Minimum Data Set, dated dated dated [DATE], indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The MDS also indicated Resident #48 required partial to moderate assistance from staff for self-feeding tasks. On 4/6/25 at 8:42 A.M., Resident #48 was observed alone in his/her room, lying in bed with his/her breakfast on the bedside table in from of him/her. The Resident was not visible from the hallway to staff walking by. The Resident was not eating his/her food. On 4/8/25 at 9:04 A.M., Resident #48 was observed sitting in his/her wheelchair next to the bed with his/her breakfast tray in front of him/her. The Resident was not eating his/her breakfast and was not visible to be supervised from the hallway. Review of Resident #48's Activities of Daily Living care plan, last revised 9/9/24, indicated the following interventions: -Eating: supv/assist (supervision/assistance) -Self-performance varies due to behaviors, cognition. Review of Resident #48's Kardex (a form indicating the level of care needed for self-care tasks) indicated the following: -Eating: supv/assist (supervision/assistance) -Self-performance varies due to behaviors, cognition. Review of the nursing summary dated 3/19/25, indicated Resident #48 required continual supervision from staff for self-feeding tasks due to inability to sequence/follow simple directions, is easily distracted, has generalized weakness, is unable to initiate or follow-through with tasks and has decreased strength and endurance. During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #48 requires someone to be with him/her at all meals because the Resident does not like to eat. CNA #1 said Resident #48 has been declining and staff have to either feed him/her or provide numerous cues throughout the meal. During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #48 does not always require physical assistance with meals and sometimes just requires supervision and cueing to continue to eat. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat. 45984 2e. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy. Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #4 is dependent on staff for activities of daily living (ADL) and requires partial/moderate assistance with eating. The surveyor made the following observations: - On 4/6/25 at 12:05 P.M., Resident #4 was sitting in a dining room and just finished lunch, he/she had various food items all over his/her chest. - On 4/7/25 at 8:07 A.M., Resident #4 was sitting in a dining room eating breakfast, he/she was observed drinking oatmeal out of a bowl and spilling it on his/her face and chest. Staff did not provide assistance or encourage the Resident to use utensils. - On 4/7/25 at 12:18 P.M., Resident #4 was sitting in the dining room eating lunch. The Resident was eating food with his/her hands and was observed to wipe his/her hands on the tablecloth as there was significant food residue on his/her hands. Staff were present in the dining room and did not provide assistance. - On 4/8/25 at 8:19 A.M., Resident #4 was sitting in a dining room eating breakfast and feeding him/herself. There was food residue on his/her chest and lap as well as on the ground below where he/she was sitting. Staff were present in the dining room but did not provide assistance. At 8:44 A.M., while Nurse #7's back was to Resident #4, the Resident attempted to drink from a cup but dropped it and it spilled all over the ground. Resident #4 then proceeded to drink oatmeal from a bowl and spill some on his/her face. Review of Resident #4's Kardex (a form indicating the level of care a resident needs) failed to indicate what level of feeding assistance he/she needs. Review of Resident #4's ADL care plan dated and revised 4/26/24 indicated the following intervention: Eating - assist. During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said Resident #4 only needs supervision with meals and he/she does okay with eating. During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' Kardex form to the know what level of feeding assistance they need. The DON said Resident #4 should be getting assistance with meals as needed. Refer to F725.

Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: Review of the facility assessment, reviewed 3/5/25, indicated: Direct Care Staffing Ratios: Unit A: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs. Unit B: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs. 2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs. Review of this facility assessment indicated total CNA staffing required for facility from 3/5/25 to 4/9/25 should be: Days 10 CNAs, Evenings 10 CNAs, Nights 7 CNAs. Review of electronic correspondence given to surveyor from the Director of Operations to the Regional Nurse, dated 4/9/25, indicated: - The facility assessment was updated in December 2024 and reviewed in QAPI 12/18/24. The staffing requirements by unit prior to the updated assessments were: A-Unit: Days 2 CNAs, Evenings 2 CNAs, Nights 2 CNAs. B-Unit: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs. 2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs. Total: Days 9 CNAs, Evenings 9 CNAs, Nights 7 CNAs - This electronic correspondence indicates CNA staffing required for 10/1/24 to 3/4/25. During the recertification survey the surveyors observed concerns with incontinence care not being provided and with odors of urine and/or body odor throughout the second floor and in one room on the first floor. During the initial tour of the facility on 4/6/25 beginning at 7:20 A.M., there were multiple concerns reported to the surveyors by residents. Seven residents and one family member expressed concerns about wishing there were more staff in the building. They said they often have to wait for a long time when they use their call lights. Some of these interviews included: - One resident who said, I learned to change my own incontinence brief because it takes too long for the call bells to be answered, and I don't want to wait. - One resident further said there is often not enough staff, especially on the weekends. The call bell takes a long time to answer, usually between a half hour to an hour. - The family member said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her meal. During the Resident Group interview on 4/8/25 at 11:05 A.M., 10 out of 16 residents expressed concerns with low weekend staffing causing long call bell wait times and medications being administered late. During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 1, 2025 (October 1, 2024 - December 31, 2024) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the weekend staff schedule, dated October 1, 2024, to December 31, 2024, indicated that the facility was staffed below their determined minimum necessary CNAs for 10 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing during this quarter: - Saturday October 12, 2024: only 6 CNAs on night shift but should have been 7. - Sunday October 13, 2024: only 5 CNAs on night shift but should have been 7. - Saturday October 26, 2024: only 8 CNAs on evening shift but should have been 9. - Saturday November 2, 2024: only 6 CNAs on night shift but should have been 7. - Sunday November 3, 2024: only 5 CNAs on night shift but should have been 7. - Saturday November 9, 2024: only 6 CNAs on night shift but should have been 7. - Sunday November 10, 2024: only 6 CNAs on night shift but should have been 7. - Sunday November 17, 2024: only 6 CNAs on night shift but should have been 7. - Sunday November 24, 2024: only 6 CNAs on night shift but should have been 7. - Sunday December 19, 2024: only 6 CNAs on night shift but should have been 7. Further review of the weekend staff schedules, dated January 1, 2025, to April 6, 2025, continued to indicate the facility was staffed below their determined minimum necessary CNAs on 9 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing: - Saturday January 4, 2025: only 6 CNAs on night shift but should have been 7. - Sunday January 5, 2025: only 8 CNAs on evening shift but should have been 9. - Saturday February 1, 2025: only 6 CNAs on night shift but should have been 7. - Sunday February 16, 2025: only 6 CNAs on night shift but should have been 7. - Sunday February 23, 2025: only 6 CNAs on night shift but should have been 7. - Saturday March 8. 2025: only 8 CNAs on evening shift but should have been 10. - Saturday March 29, 2025: only 6 CNAs on night shift but should have been 7. - Sunday March 30, 2025: only 8 CNAs on day shift but should have been 10. - Sunday March 30, 2025: only 9 CNAs on evening shift but should have been 10. During an interview on 4/07/25 at 9:39 A.M., Nurse #6 said sometimes there is trouble with scheduling/rescheduling appointments because of inconsistent staffing. During an interview on 4/8/25 at 9:45 A.M., Nurse #5 said she sometimes hears CNAs say they have trouble getting all the care completed because of staffing. During an interview on 4/9/25 at 8:40 A.M., CNA #6 said she works day shift consistently. CNA #6 said when there are ten CNAs on day shift, they can get everything done, but when there is less the CNAs must rush to get the care done. During an interview on 4/9/25 at 9:48 A.M, the Scheduler said CNA staffing is currently 9 CNAs on the day shift, 9 CNAs on the evening shift, and 7 CNAs on the night shift (instead of what the facility assessment, dated 3/5/25 indicated). The scheduler said sometimes it's not met because of call outs or because he just can't get the staff. The Scheduler said if the facility is short staffed, CNAs say they feel overworked and that they must rush through care. During an interview on 4/9/25 at 9:57 A.M., the Administrator said he would expect staff levels to be met as determined what was required based on the census. The Administrator said he has been at the facility since January 2024 and had never been notified of not meeting the required staffing levels but would have expected to be. The Administrator said he would expect the facility to follow staffing ratios determined to be necessary to provide care in either the facility assessment or determined ratios. During an interview on 4/9/25 at 12:35 P.M., the Regional Nurse said the facility assessment was reviewed in December 2024 in regard to staffing level required based on the census. The Regional Nurse gave the surveyor the above mentioned electronic correspondence that indicated from October 1, 2024, to March 4, 2025, the CNA staffing for the facility should have been 9 CNAs on day shift, 9 CNAs on evening shift, and 7 CNAs on night shift. The Regional Nurse said the facility assessment was updated 3/5/24 and the staffing was updated to require more based on the increased facility census and should have been 10 CNAs on day shift, 10 CNAs on evening shift, and 7 CNAs on night shift starting 3/5/25 to present.

Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the comprehensive Facility Assessment Tool, revised 3/5/25, included but was not limited to the following: - Services Provided Based on Resident Assessment and Care Plans: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Staff training/Education and Competencies: The facility uses [an electronic training system] for various training modules, which are assigned and completed throughout the year. Each module includes exam questions at the end to assess the staff's understanding. Additionally, an annual competency fair is conducted, allowing staff to practice and demonstrate required competencies. - Yearly Education for All Staff: Skin/Wound Care. Review of the facility's training plan titled 'Annual Licensed Nurse Skills Competencies and Checklists', undated, indicated, but was not limited to: - Training Plan Description: Developing clinical competency is important for each nurse in order to deliver quality care. This Annual Licensed Nurse training plan is completed with the ADON (Assistant Director of Nursing), Staff Development Coordinator (SDC) or Designee to facilitate the mastery of nursing skills. - The checklists follow each step of the skill to provide a complete evaluative tool. They are designed to record an evaluation of each step of the procedure as met or not met. - Training Plan Module List: Clean a Wound and Apply a Dry Non-Sterile Dressing Skills Checklist, Wound Documentation Skills Checklist. Throughout the recertification survey (4/6/25 through 4/9/25) the surveyors identified multiple concerns regarding wound care. The surveyor reviewed staff education files for wound competencies for five licensed nurses currently working in the facility: - 3 out of 5 nurses failed to have evidence of wound care competencies completed in the last year or upon hire. During an interview on 4/9/25 at 11:09 A.M., the Regional Nurse said all nurses are required to complete annual competencies for wound care. The Regional Nurse said she reached out to the regional office, who was also unable to locate the missing annual/on hire wound competencies for the above mentioned three nurses. During an interview on 4/11/25 at 11:23 A.M., The Director of Nursing (DON) said annual competencies and training should be monitored to ensure they are completed, but that there has been a lot of turnover in the staff development role. The DON said the staff development role was vacant about a year ago and was briefly filled in May, June, July and again briefly later in the year. The DON said the role has been being covered by herself and various other staff. The DON was unable to provide the name of a person primarily responsible for monitoring that competencies were completed during the times there was not a staff development nurse.

Based on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 5 of 5 Certified Nurse Aides (CNAs) personnel files reviewed. Findings include: Review of 5 Certified Nurse Aides (CNAs) personnel files, who had been employed by the facility for over 12 months, indicated: - 5 out of 5 failed to include documentation of an annual performance review. During an interview on 4/9/25 at 11:34 A.M., the Director of Nursing (DON) said all CNAs are required to have annual performance reviews completed and the documentation of completion should be readily available. The DON said she was unable to locate any of the 5 CNA annual performance reviewed requested by the surveyor.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart, treatment carts on the first and second floor and the second floor's medication room were locked while a nurse was not present. Findings include: Review of the facility policy titled, Storage of Medications, dated 8/20, indicated the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. On 4/6/25 at 6:47 A.M., the surveyor observed the medication cart on the first floor unlocked and unsupervised. No staff were present at the cart, the surveyor was able to access the cart and medications. On 4/6/25 at 7:18 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it. On 4/6/25 from 7:18 A.M. to 12:54 P.M., the surveyor observed the treatment cart on the second floor unlocked and unsupervised outside of resident rooms. No staff were present at the cart, the surveyor was able to access the cart. The nurse was not present at the nurses station. On 4/6/25 at 11:45 A.M. the surveyor observed a first floor treatment cart unlocked and unsupervised next to the visitors bathroom and staff bathroom. No staff were present at the cart, the surveyor was able to access the cart. On 4/7/25 at 7:01 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it. The nurse was not present at the nurses station. During an interview on 4/8/25 at 8:08 A.M., Nurse #3 said medication rooms, medication and treatment carts should be locked unless a nurse in the room and at the cart. During an interview on 4/08/25 at 2:14 P.M., the Director of Nursing said she expects medication rooms, medication and treatment carts should be locked unless a nurse is present in the room or at the carts.

Based on interviews and records reviewed, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to develop comprehensive care plans to address substance use disorders, and failed to ensure they provided qualified staff to ensure they provided knowledge and expertise in caring for resident(s) with substance use disorder. -Resident #1 was found, on 7/5/17 and 9/9/17 to have obtained and ingested [MEDICATION NAME] (opioid) while at the Facility, and required hospitalization for opioid overdose on 9/9/17, where he/she required two doses of [MEDICATION NAME] (opioid reversal agent). Resident #1 did not have a plan of care related to his/her substance use disorder that included interventions to remain drug free while in the Facility, or need for supportive services. -Resident #3 was admitted to the Facility 7/31/17 after being hospitalized due to intoxication. Resident #3 did not have a plan of care to address his/her use of alcohol, and there were no interventions to help Resident #3 maintain sobriety in the Facility. Findings include: The protocol titled, Care Plan Interventions for Relapse Prevention, Maintaining Sobriety, Identifying Signs of Relapse, undated, indicated the Facility would know and report triggers, stressors, situations that provoke anxiety, identify motivators for maintaining sobriety, and watch for behaviors and signs of both mental and physical indicators for relapse. The policy titled, Substance Use/Abuse Screening, dated 8/1/16, indicated the Facility would conduct a Substance Use Assessment Tool upon admission, a plan of care would be formulated to ensure proper interventions would be put into place, and the resident would be monitored to determine further interventions needed. 1. Resident #1 was admitted to the Facility 10/21/2015, and his/her [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13-15 indicates cognitively intact), and Resident #1 was his/her own responsible person and could make his/her own decisions Nurse Practitioner #1's Progress Note, dated 7/5/17, untimed, indicated she was asked by nursing staff on the afternoon of 7/5/17 to assess Resident #1, and it was reported to Nurse Practitioner #1 that Resident #1 had been disoriented, eyes were rolling, incontinent of urine, and unsteady gait the previous day. The Note indicated a toxicology screen was ordered. The Serum Drug Abuse Panel Report, dated 7/5/17, indicated Resident #1 tested positive for [MEDICATION NAME], which was not prescribed to him/her. The Care Plan, dated 7/14/17, and revised on 9/2/17, indicated Resident #1 was not compliant with care, had been found to have [MEDICATION NAME] in his/her blood work, which he/she was not prescribed. Interventions included support services. The Care Plan did not include interventions to address and provide for the needed care and services related to Resident #1's substance use disorder. The Behavioral Health Progress Note, dated, 7/17/17, indicated Resident #1 admitted to taking some pills from an unknown source, and he/she expressed remorse. The Behavioral Health Progress Note, dated, 8/8/17, indicated Resident #1 was experiencing anxiety related to his/her housing situation, and expressed that he/she wanted to get out of the Facility, and was tired of sitting around all day watching television. The Behavioral Health Progress Note, dated, 8/15/17, indicated Resident #1 reported he/she was increasingly frustrated, and said he/she was going to go crazy if he/she needed to stay in the Facility much longer. The Behavioral Health Progress Note, dated, 9/5/17, indicated Resident #1 continued to have anxiety and frustration related to living at the Facility. Resident #1's clinical record did not include a plan of care or interventions to address Resident #1's known history of substance use disorder, there was no documentation in the clinical record to indicate that an assessment was conducted related to Resident #1's substance use disorder upon admission to the Facility, or that Resident #1 was reassessed for substance use disorder after he/she was found to have ingested an opioid medication not prescribed to him/her while at the Facility in July 2017. The emergency room Report, dated 9/9/17, indicated Resident #1 was brought to the emergency room by ambulance, had rapid heart rate, low oxygen saturation, glassy eyes, and unsteady gait, was administered [MEDICATION NAME] twice with good effect. The Report indicated the Facility reported there was a suspicion that Resident #1 had abused substance(s). The Report indicated Resident #1 admitted to having ingested 20 tablets of [MEDICATION NAME] (opioid) on the evening of 9/8/17. The Report indicated required admission to the hospital for treatment of [REDACTED]. The Substance Use Assessment Tool, undated and signed by the Director of Nurses, indicated Resident #1 had a past history of heroin and [MEDICATION NAME] use, and indicated Resident #1 was in control of his/her substance use disorder. (The Surveyor clarified with the Director of Nurses the Substance Use Assessment Tool was completed after Resident #1 was hosptalized on [DATE].) This was inconsistent with the policy titled, Substance Use/Abuse Screening, dated 8/1/16. The Behavioral Health Progress Note, dated 9/12/17, indicated Resident #1 was frustrated regarding his/her housing situation, and he/she was struggling with his/her ability to remain substance free. The Surveyor interviewed Resident #1 at 3:22 P.M. on 10/10/17. Resident #1 said he/she had obtained 20 tablets of [MEDICATION NAME] from an outside source, and ingested all of the [MEDICATION NAME] some time during the evening of 7/3/17. Resident #1 said the Facility did not offer services to help with his/her substance use disorder in July 2017. The Surveyor interviewed Social Worker #1 at 2:20 P.M. on 10/10/17. The Social Worker said there was not a substance use disorder support system at the Facility, and she was not aware of any contracted services offered for substance or alcohol use treatment within the Facility. The Social Worker said she was not aware of Resident #1's opioid use that occurred on 7/4/17 until after Resident #1 was transferred to the hospital on [DATE]. The Surveyor interviewed the Director of Nurses at 1:41 P.M. on 10/10/17. The Director of Nurse said Resident #1's mental health counseling was reinstated on 7/10/17, after a lapse in services from 4/18/17. The Director of Nurses said there was a meeting held with the Medical Director, the Administrator, Resident #1, and herself on 7/14/17 to discuss Resident #1's recent substance use, and said at that time there were no further interventions put in place, as it was the first time Resident #1 had used drugs since his/her admission in 10/2015. 2. Resident #3 was admitted to the Facility 7/31/17, and his/her [DIAGNOSES REDACTED]. The Care Plan, dated 8/1/17, indicated Resident #3 was his/her own responsible person and could make his/her own decisions. The Care Plan did not include interventions to address and provide for the needed care and services for Resident #3's alcohol use disorder. The MDS assessment dated , 8/7/17, indicated a BIMS score of 15 out of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's clinical record indicated there was no documentation to support that a Substance Use Assessment Tool was completed upon admission. The Surveyor interviewed the Regional Director of Clinical Operations at 11:52 A.M. on 10/10/17. The Regional Director of Clinical Operations said the Facility did not have a substance use counselor, could not provide the necessary treatment for [REDACTED]. The Surveyor interviewed the Director of Nurses at 1:41 P.M. and throughout the day on 10/10/17. The Director of Nurses said no other resident in the Facility had a Substance Abuse Assessment completed, and the Substance Abuse Assessment was not completed upon admissions. This was inconsistent with the policy titled, Substance Use/Abuse Screening, dated 8/1/16. The Surveyor interviewed several direct care staff members throughout the survey regarding knowledge of necessary care and treatment for [REDACTED]. -The Surveyor interviewed the Assistant Director of Nurses, Nurse #4, and Nurse #5 at various times on 10/10/17. -The Assistant Director of Nurses said he was not aware of any current staff education related to substance use disorder. -Nurse #4 said if she thought a resident had abused substance(s), she would help the resident to bed and monitor him/her. Nurse #4 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not have [MEDICATION NAME] (opioid reversal agent) available for emergency administration. -Nurse #5 said the Facility did not have [MEDICATION NAME] available for emergency administration. The Surveyor interviewed Nurse #1 and Nurse Practitioner #1 at different times throughout the day on 10/11/17. -Nurse #1 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not train staff on the administration of [MEDICATION NAME], and [MEDICATION NAME] was not available at the Facility. -Nurse Practitioner #1 said the Facility did not have [MEDICATION NAME] available for emergency administration, and said [MEDICATION NAME] administration was the responsibility of Emergency Medical Services. The Surveyor interviewed the Director of Nurse at 12:23 P.M. on 10/12/17. The Director of Nurses said the Facility stored one dose of [MEDICATION NAME] in a kit in the A Unit medication room. The Director of Nurses said she did not know the process for staff to assess the need for or to administer [MEDICATION NAME], and said she thought staff would call 911 in an emergency situation. The Surveyor interviewed the Medical Director at 3:24 P.M. on 10/13/17. The Medical Director said he did not know if the Facility had a policy regarding [MEDICATION NAME] availability and administration, and said there should be staff trained and [MEDICATION NAME] available to be administered in the event of opioid overdose.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to provide the necessary treatment for [REDACTED].#1 who had a known history of substance use disorder. On 9/9/17 Resident #1 was assessed by nursing as having a change in mental status, unsteady gait, changes in vital signs, and difficulty breathing (all possible signs of substance use). -Nursing staff said [MEDICATION NAME] (opioid reversal agent) was not available for administration, and were not educated and trained regarding the signs and symptoms of, monitoring, and emergency treatment for [REDACTED]. -The Hospital discharge summary indicated Resident #1 was treated for [REDACTED]. Findings include: The protocol titled, Recognizing Signs of an Overdose for Depressants (opioids, heroin, [MEDICATION NAME], etc), undated, indicated sighs of an overdose included an erratic heartbeat and erratic breathing. The protocol titled, Preventing Substance Use Relapse Plan, undated, indicated Nursing and Social Services Staff would be provided education on relapse risk and prevention monthly to provide adequate support. The policy titled, [MEDICATION NAME] Policy, undated, indicated staff would be knowledgeable about, and would be proactive in conducting emergency procedures to facilitate the prompt assessment and pre hospital treatment of [REDACTED]. Resident #1 was admitted to the Facility 10/2015, his/her [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 7/28/17, indicated Resident #1's Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13-15 indicates cognitively intact), Resident #1 did not have a guardianship in place, was his/her own responsible person and could make his/her own decisions On 7/4/17, Resident #1 was assessed as having had a change in mental status, was having incoherent conversations, and had an unsteady gait. It was later found, on the toxicology screen, that Resident #1 had [MEDICATION NAME] (opioid), in his/her system, which was not prescribed to him/her. The Order Summary Report, dated 9/1/17, did not indicate Resident #1 was prescribed [MEDICATION NAME] in the event of a suspected or known opioid overdose. The Nurse Progress Note, dated 9/9/17, timed 2:22 P.M. indicated, Resident #1 was assessed as being confused, had slurred speech, unsteady gait, was shaking and sweating, had flushed skin, a high heart rate of 146 beats per minute, (normal resting heart rate for adults ranges from 60 to 100 beats a minute), and low oxygen saturation, (potential symptoms of opioid overdose). The Note indicated Resident #1 was transferred to the emergency room after activating 911. There was no documentation to indicate staff administered [MEDICATION NAME] to Resident #1. The emergency room Report, dated 9/9/17, indicated Resident #1 was brought to the emergency room by ambulance, had rapid heart rate, low oxygen saturation, glassy eyes, and unsteady gait, was administered [MEDICATION NAME] twice with good effect. The Report indicated Resident #1 admitted to having ingested 20 tablets of [MEDICATION NAME] (opioid) on the evening of 9/8/17. The Report indicated Resident #1 required admission to the hospital for treatment of [REDACTED]. The Surveyor interviewed Nurse #3 at 3:24 P.M. on 10/13/17. Nurse #3 said some time in the morning on 9/9/17 she noticed Resident #1 was walking with an unsteady gait, and she assessed him/her as having as having a change in mental status, difficulty breathing, and low oxygen level. Nurse #3 said asked Resident #1 if he/she had taken any drugs, and said she did report to the emergency room that Resident #1 that she suspected Resident #1 had taken drugs. Nurse #3 said the Facility did not have [MEDICATION NAME] available for administration, and staff was not trained on the necessary care and treatment for [REDACTED]. The Surveyor interviewed several direct care staff members throughout the survey regarding knowledge of necessary care and treatment for [REDACTED]. -The Surveyor interviewed the Assistant Director of Nurses, Nurse #4, and Nurse #5 at various times on 10/10/17. -The Assistant Director of Nurses said he was not aware of any current staff education related to substance use disorder. -Nurse #4 said if she thought a resident had abused substance(s), she would help the resident to bed and monitor him/her. Nurse #4 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not have [MEDICATION NAME] available for emergency administration. -Nurse #5 said the Facility did not have [MEDICATION NAME] available for emergency administration. The Surveyor interviewed Nurse #1 and Nurse Practitioner #1 at different times throughout the day on 10/11/17. -Nurse #1 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not train staff on the administration of [MEDICATION NAME], and [MEDICATION NAME] was not available at the Facility. -Nurse Practitioner #1 said the Facility did not have [MEDICATION NAME] available for emergency administration, and said [MEDICATION NAME] administration was the responsibility of Emergency Medical Services. The Surveyor interviewed the Director of Nurse at 12:23 P.M. on 10/12/17. The Director of Nurses said the Facility stored one dose of [MEDICATION NAME] in a kit in the A Unit medication room. The Director of Nurses said she did not know the process for staff to assess the need for or to administer [MEDICATION NAME], and said she thought staff would call 911 in an emergency situation. The Surveyor interviewed the Medical Director at 3:24 P.M. on 10/13/17. The Medical Director said he did not know if the Facility had a policy regarding [MEDICATION NAME] availability and administration, and said there should be staff trained and [MEDICATION NAME] available to be administered in the event of opioid overdose.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure there were practices in place to uphold his/her right to freely exit the building. Resident #1 was his/her own responsible person, was able to make his/her own decisions, and the Facility actively prohibited him/her from leaving the building, causing Resident #1 to feel trapped, resulting in emotional harm. Findings include: Resident #1 was admitted to the Facility 10/21/2015, and his/her [DIAGNOSES REDACTED]. The Quarterly Interdisciplinary Resident Review, dated 7/26/17 indicated Resident #1 was not at risk for elopement. The Quarterly Minimum Data Set (MDS) assessment, dated 7/28/17, indicated Resident #1's Brief Interview for Mental Status (BIMS) score was a 15 (score of 13-15 indicates cognitively intact), Resident #1 did not have a guardianship in place, was his/her own responsible person and could make his/her own decisions The physician's orders [REDACTED].#1 would be allowed to leave the Facility every other day for a period of 30 minutes, and if he/she was late to return or showed any symptoms of intoxication, he/she would be subject to drug testing and his/her privilege would be revoked, and review in one week. The physician's orders [REDACTED].#1 would be allowed to leave the Facility for one hour every other day for a period of one week, and review in one week. The emergency room Report, dated 9/9/17, indicated Resident #1 was brought to the emergency room by ambulance, had rapid heart rate, low oxygen saturation, glassy eyes, and unsteady gait, was administered [MEDICATION NAME] (opioid reversal agent) twice with good effect. The Report indicated the Facility reported there was a suspicion that Resident #1 had abused substance(s). The Report indicated Resident #1 admitted to having ingested 20 tablets of [MEDICATION NAME] (opioid) on the evening of 9/8/17. The Report indicated Resident #1 required admission to the hospital for treatment of [REDACTED]. Nurse Practitioner #2's progress note, dated 9/12/17, indicated Resident #1 had returned from a hospital admission with new [DIAGNOSES REDACTED]. The note indicated Resident #1's privileges to leave the Facility were stopped. The physician's orders [REDACTED].#1. The Surveyor interviewed Nurse Practitioner #1 at 12:01 P.M. on 10/11/17. Nurse Practitioner #1 said Resident #1 was his/her own responsible decision maker, Resident #1 had improved mental health while he/she was going for walks in the community, and said Resident #1 had requested to have his/her privileges reinstated to be able to walk outside in the community. Nurse Practitioner #1 said she was reluctant to let Resident #1 leave the Facility unattended, due to his/her history of substance use disorder. The Behavioral Health Progress Note, dated 9/12/17, indicated the Facility had canceled Resident #1's privileges to go out alone, which was fueling his/her anger. The Surveyor interviewed Resident #1 at 3:22 P.M. on 10/10/17. Resident #1 said he/she used to enjoy going for walks outside the Facility, and the walks helped him/her clear his/her head and get away from people. Resident #1 said he/she felt angry and trapped because the Facility took away his/her privileges to leave the Facility on his/her own. The Surveyor interviewed the Director of Nurses at 1:41 P.M. and throughout the day on 10/10/17. The Director of Nurses said Resident #1 was his/her own decision maker, and said his/her privileges to leave the Facility were revoked after he/she was hosptalized on [DATE] when he/she was found to have overdosed on [MEDICATION NAME] while at the Facility. The Director of Nurses said Resident #1 had expressed he/she was not happy that his/her LOA privileges were taken away, and said he/she wanted his/her privileges to leave the Facility reinstated.

Based on interviews and records reviewed, for one of three sampled residents, (Resident #1), the Facility failed to provide the necessary supervision to prevent Resident #1, who had a known history of substance use disorder, from obtaining and using substances while at the Facility. On 7/4/17 and again on 9/9/17, Resident #1 was found to have taken Morphine (opioid) tablets, which were not prescribed to him/her, and Resident #1 required hospitalization and two doses of Naloxone (opioid reversal agent) for opioid overdose from 9/9/17 through 9/11/17. Findings include: The protocol titled, Preventing Substance Use Relapse Plan, undated, indicated social services would the Facility would monitor residents at risk for relapse of substance use disorder to determine other added interventions needed. Resident #1 was admitted to the Facility 10/21/2015, and his/her [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13-15 indicates cognitively intact), and Resident #1 was his/her own responsible person and could make his/her own decisions. The Surveyor interviewed Resident #1 at 3:22 P.M. on 10/10/17. Resident #1 said he/she had obtained 20 tablets of Morphine from an outside source, and ingested all of the Morphine some time during the evening of 7/3/17. Resident #1 said he/she felt good at first, but said he/she felt sick and was having a hard time breathing and felt his/her heart was racing the next day, and he/she said he/she felt out of it, or words to that effect. The Nurse Progress Note dated 7/4/17, timed 7:52 P.M. indicated Resident #1 had slurred speech, and was off topic with conversation. The progress note indicated Resident #1's blood pressure was 119/69 mmHg (blood pressure is normal if it's below 120/80 mm Hg), and heart rate was 73 beats per minute (bpm) (normal resting heart rate for adults ranges from 60 to 100 beats a minute). The Note indicated that later, Resident #1's blood pressure was 154/65 mmHg, and heart rate was 133 bpm, which was a significant change. The Note indicated Resident #1 refused medical attention and stated he/she was ok, and Resident #1 was encouraged to sleep. The Surveyor interviewed Nurse #2 at 11:18 A.M. on 10/12/17. Nurse #2 said she had cared for Resident #1 during the 3:00 P.M. to 11:00 P.M. shift on 7/4/17. Nurse #2 said she had been told at shift change report that Resident #1 had slurred speech, was incoherent, and the previous shift nurse said she thought Resident #1 had taken some drugs, or words to that effect. The Nurse Progress Note dated 7/5/17, timed 6:20 A.M. indicated Resident #1 was alert, oriented, congested, coughing, had difficulty walking, and his/her blood pressure was 143/77 mmHg, with a heart rate of 130 bpm. The Surveyor interviewed Nurse #1 at 2:40 P.M. on 10/11/17. Nurse #1 said that she cared for Resident #1 on the 11:00 P.M. to 7:00 A.M. shift on 7/4/17 to 7/5/17. Nurse #1 said she had arrived early for the shift but she could not recall the exact time she arrived. Nurse #1 said she had been told during change of shift report from Nurse #2 that Resident #1 had a change in mental status, and he/she seemed out of it, or words to that effect. Nurse Practitioner #1's Progress Note, dated 7/5/17, untimed, indicated she was asked by nursing staff on the afternoon of 7/5/17 to assess Resident #1 due to Resident #1's altered clinical status as assessed the previous morning and throughout the previous day. The Note indicated staff reported Resident #1 had been disoriented, had an unsteady gait, and had been incontinent of urine, which was not his/her baseline. The Note indicated a toxicology screen was ordered. The Serum Drug Abuse Panel Report, dated 7/5/17, indicated Resident #1 tested positive for Morphine, which was not prescribed to him/her. The Care Plan, dated 7/14/17, and revised on 9/2/17, indicated Resident #1 was not compliant with care, and had been found to have Morphine in his/her blood work, which he/she was not prescribed. Interventions included support services. The Care Plan did not include interventions to address and provide for the needed care, supervision, and services related to Resident #1's substance use disorder. The emergency room Report, dated 9/9/17, indicated Resident #1 was brought to the emergency room by ambulance, had rapid heart rate, low oxygen saturation, glassy eyes, and unsteady gait, was administered Naloxone twice with good effect, and required admission to the hospital for treatment of [REDACTED]. The Report indicated the Facility reported there was a suspicion that Resident #1 had abused substance(s). The Report indicated Resident #1 admitted to having ingested 20 tablets of Morphine (opioid) on the evening of 9/8/17. The Surveyor interviewed The Social Worker at 2:20 P.M. on 10/10/17. The Social Worker said she was not aware of Resident #1's opioid use that occurred on 7/4/17 until after Resident #1 was transferred to the hospital on [DATE]. The Surveyor interviewed the Director of Nurses at 1:41 P.M. on 10/10/17. The Director of Nurses said Resident #1 had no known history of substance use since his/her admission in October 2015, therefore the plan of care was not updated to include increased supervision following Resident #1's substance use on 7/4/17. This was inconsistent with Resident #1's admission diagnosis.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) with substance use disorders, the Facility failed to ensure Resident #1 received a comprehensive medical interdisciplinary evaluation to determine the severity of the issue, develop treatment priorities; failed to determine his/her immediate psychiatric or substance use disorder care needs, evaluate his/her risks, and strengths, and failed to identify specific services needed as they related to substance use disorder. The Facility failed to ensure they provided qualified staff to ensure they provided knowledge and expertise in caring for resident(s) with substance use disorder. Review of Resident #1's clinical record indicated, on 7/3/17 and again on 9/9/17, Resident #1 was found to have ingested [MEDICATION NAME] (opioid) which was not prescribed to him/her. Although Resident #1 was found to be actively abusing a substance while in the Facility, there was no effort by the Facility to evaluate Resident #1's substance use, risk to self, or consideration for the Facility's ability or inability to provide Resident #1 with the safest setting to meet his/her health care needs, including active substance use or addiction. There was no indication a comprehensive medical evaluation by a qualified addiction specialist was performed following the 7/3/17 or 9/9/17 incidents. Findings include: The policy titled, [MEDICATION NAME] Policy, undated, indicated each resident's substance use risk would be assessed on admission, quarterly, annually, and with significant change in condition. If the resident admits to still having substance use issues, they would be encouraged to participate in Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) meetings offered in house by psych, social services, and medical treatment. The policy titled, Residents with Psychiatric and/or Substance Abuse Problems, dated 4/30/17, indicated the Facility would not accept residents whose primary care needs relate to psychiatric or substance abuse issues, and patients may be accepted for rehabilitation care who also have these conditions provided the Facility was able to meet the needs of the resident, and provide adequate safeguards for the resident, visitors, and staff. This policy was inconsistent with Facility practice. The Facility-wide [DIAGNOSES REDACTED]. Resident #1 was admitted to the Facility in 10/2015 following a hospitalization after a heroin overdose at another skilled nursing facility, and had a known history of substance use disorder. Review of Resident #1's clinical record indicated there was no comprehensive assessment of Resident #1's needs related to substance use disorder or addiction prior to 9/2017. The Surveyor interviewed several direct care staff members throughout the survey regarding knowledge of necessary care and treatment for [REDACTED]. -The Surveyor interviewed the Assistant Director of Nurses, Nurse #4, and Nurse #5 at various times on 10/10/17. -The Assistant Director of Nurses said he was not aware of any current staff education related to substance use disorder. -Nurse #4 said if she thought a resident had abused substance(s), she would help the resident to bed and monitor him/her. Nurse #4 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not have [MEDICATION NAME] available for emergency administration. -Nurse #5 said the Facility did not have [MEDICATION NAME] available for emergency administration. The Surveyor interviewed Nurse #1 and Nurse Practitioner #1 at different times throughout the day on 10/11/17. -Nurse #1 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not train staff on the administration of [MEDICATION NAME], and [MEDICATION NAME] was not available at the Facility. -Nurse Practitioner #1 said the Facility did not have [MEDICATION NAME] available for emergency administration, and said [MEDICATION NAME] administration was the responsibility of Emergency Medical Services. The Surveyor interviewed the Regional Director of Clinical Operations at 11:52 A.M. on 10/10/17. The Regional Director of Clinical Operations said the Facility did not have a program to provide necessary support to residents with current substance use disorder and said the Facility did not offer in-house NA or AA meetings, and there was not a substance use disorder counselor available at the Facility. The Surveyor interviewed Nurse #3 at 3:24 P.M. on 10/13/17. Nurse #3 said the Facility had not provided training or education related to signs and symptoms or emergency treatment related to opioid overdose or substance use disorder, and said the Facility did not have [MEDICATION NAME] available for emergency administration. The Surveyor interviewed the Regional Director of Clinical Operations at 11:52 A.M. on 10/10/17. The Regional Director of Clinical Operations said the Facility did not have a program to provide necessary support to residents with current substance use disorder and said the Facility did not offer in-house NA or AA meetings, and said there was not a substance use disorder counselor available at the Facility. The Surveyor interviewed the Assistant Director of Nurses at 5:00 P.M. on 10/10/17. The Assistant Director of Nurses said he was not aware of any current staff education program related to substance use disorder.

Based on records reviewed and interviews, for 1 out of 3 sampled Residents (Resident #1), the Facility failed to provide adequate supervision to prevent elopement. On 11/7/16 at approximately 11:00 A.M., Resident #1, who was cognitively impaired, had a history of [REDACTED]. After the appointment Resident #1 walked out of the Physician's office by himself/herself, could not be located, and the Facility filed a Missing Person Report with the Police Department. When Resident #1 was located, approximately 8.5 hours later, he/she was transferred to the Hospital where he/she told Emergency Department staff that he/she was walking around all day, drinking alcohol, and had pain in his/her right hip from being on his/her feet for a long period of time. Resident #1 was treated for [REDACTED]. Findings Include: A Quarterly Minimum Data Set (MDS) assessment, dated 1/26/17, indicated Resident #1 included a [DIAGNOSES REDACTED]. A Quarterly Interdisciplinary Resident Review Assessment, dated 10/12/16, indicated Resident #1 had impaired long and short term memory, needed assistance making decisions, and had a history of [REDACTED]. An Investigation Summary, dated 4/5/16, indicated that, on 4/5/16, Resident #1 walked out of a Physician's office after an appointment, attempted to walk back to the Facility alone, and was escorted back to the Facility by Police. A Safety Risk Care Plan, dated 12/26/15, indicated Resident #1 was forgetful, impulsive, and made poor choices. The Care Plan included an intervention, dated 4/5/16, for a Certified Nursing Assistant (CNA) to accompany Resident #1 to all appointments in the Community. However, on 11/7/16, the Facility did not send a CNA to accompany Resident #1 to a Physician's appointment. This was inconsistent with Resident #1's Safety Risk Care Plan. A Behavior Care Plan, dated 9/2/15, indicated Resident #1 had a history of [REDACTED]. Surveyor #1 interviewed Nurse #1 on 2/21/17 at 11:00 A.M. Nurse #1 said, on 11/7/16, Resident #1 had a morning appointment with a Neurologist and he was unaware that Resident #1 required a CNA to accompany him/her to the appointment. Nurse #1 said he was not aware Resident #1 was at Risk for Elopement, did not know what Resident #1's Care Plan indicated, was unsure if the Facility had any means to identify Residents who were at Risk for Elopement, and was not informed about a process the Facility had in place that identified Residents at risk for elopement. A Progress Note, dated 11/7/16 and timed at 3:44 P.M., indicated Resident #1 had a 10:30 A.M. Physician appointment and, at 1:30 P.M., the ambulance company scheduled to transport Resident #1 back to the Facility after his/her appointment called to inform them that Resident #1 was not at the Physician's office when they arrived to pick him/her up. Surveyor #1 interviewed Nurse #2 on 2/17/17 at 1:22 P.M. Nurse #2 said on 11/7/16, although she could not recall the time, she and the Director of Nursing at the time of the incident, drove to the Physician's office to look for Resident #1 but they were unable to locate him/her at the office or when they drove around the area, and went to the Police Station to file a Missing Person Report, when they were unable to find him/her. The Facility submitted an Incident Report, for an Elopement/Missing Person, to the Department of Public Health on 11/8/16. The Report indicated that the Director of Nursing was notified that Resident #1 was missing at 1:40 P.M. and at approximately 2:00 P.M. she drove to the Physician's office, which was the location where Resident #1 was last seen. A Police Report titled Missing Person, dated 11/7/16 and filed at 4:17 P.M. by Nurse #2, indicated that Resident #1 was last seen by staff at the location of the Physician's office at 12:45 P.M. The Hospital Emergency Department (ED) Report, dated 11/7/16 indicated that Resident #1 arrived at the ED via ambulance at 9:25 P.M., which was approximately 8.5 hours after he/she was last seen at the Physician's office, and Resident #1 had complaints of right hip pain from being on his/her feet for a long period of time and Resident #1 told the ED Physician that he/she drank alcohol and walked around all day. The report further indicated that Resident #1 had been a patient at the Hospital several times in the past and had a history of [REDACTED].#1 was evaluated and treated for [REDACTED].M., which was approximately 12.5 hours after Resident #1 had left the Facility that morning.

Based on interview, record review and observations, the facility failed to provide timely social services to support and address a resident with a known history of agitation and resident to resident altercations who voiced concerns and requested a room change on 10/19/16 due to an emerging conflict with his/her roommate, subsequently there was a resident to resident altercation between Resident #8 and Resident #11 causing harm to Resident #8 out of 18 sampled residents. Findings include: During initial tour on 10/20/16 at 8:20 A.M., Nurse #1 said that Resident #8 had transferred from the first floor to the second floor within the past few weeks after getting into a physical altercation with a resident downstairs. She said that on the morning of 10/19/16, Resident #8 asked for a room change because he/she was not getting along with his/her roommate, (Resident #11). Nurse #1 said that she brought this to the attention of the team during morning meeting and that Resident #8's request for a room change would be deferred until the facility Social Worker returns from vacation the following week. Nurse #1 said that later in the evening on 10/19/16, Resident #8 was punched by Resident #11 and both residents were sent to the hospital. Resident #8 returned with new [DIAGNOSES REDACTED]. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. His/her most recent Minimum Data Set, (MDS), dated [DATE] indicated that he/she has some cognitive impairments and requires assistance with bathing, dressing and transfers. Review of Resident #8's clinical behavior careplan indicated that he/she is easily angered, verbally abusive and accusatory. Resident #8's safety and potential for abuse careplan dated 9/22/16 indicated the goal of keeping him/her safe and free from abuse and indicated the following interventions: -Change room or unit as needed, (dated 10/3/16) -Do not have Resident #8 near others that disturb him/her, (dated 9/22/16) -Do not have Resident #8 near others that he/she disturbs, (dated 9/22/16) -Remove from potentially dangerous situations, (dated 9/22/16) Review of Resident #8's clinical record indicated that on 10/19/16, Resident #8 was agitated with his/her roommate, Resident #11. The nurses note indicated that Resident #8 had words with Resident #11, and Resident #11 pushed Resident #8's bedside table and walker away from his/her bed. Resident #8 requested to be moved to another room that had a bed available and the note indicated that this request would be addressed with Social Worker on Monday. (10/24/16) During interviews with Nurse #1, Nurse #2, CNA #1, and the MDS Coordinator, all said that Resident #8 has a history of resident to resident altercations; both physical and verbal. CNA #1 said that Resident #8 did not like his/her current roommate and that when Resident #8 becomes agitated, it is best to leave him/her alone and come back later. Nurse #2 said that Resident #8 historically has had issues with roommates and other residents since his/her admission to the facility. During interview with Resident #8 on 10/20/16 at 11:57 A.M., Resident #8 said that he/she was upset with how long it took for him/her to get in a new room and that he/she does not feel safe at the facility. Resident #8 said that Resident #11 had been swearing at him/her for the past three days. Resident #8 said that on 10/19/16 he/she had asked the nurse for a room change because he/she was not getting along with Resident #11. Resident #8 said that he/she then spoke with the Admissions Coordinator and was told that he/she would not be able to have a room change done until the facility Social Worker came back from vacation. During interview with the Admissions Coordinator on 10/21/16 at 7:57 A.M., she said that she spoke with Resident #8 on 10/19/16. She said that Resident #8 doesn't get along with other residents. She said that the facility Social Worker handles room changes and that Resident #8 was told the room change would have to wait until the Social Worker returned from vacation. During follow up interview with the Social Worker on 10/24/16, he said that room changes can and have occurred when he is not in the building, especially when it is necessary to separate individuals for safety. During interview with the Director of Nursing, (DON) and the Interim Director of Nursing, (IDON), on 10/21/16, the DON said that room change decisions were made as a team, but if a room change was needed for safety reasons it would be done immediately. The DON confirmed that there were open beds available in the facility for Resident #8 at the time of his/her request to change rooms. The DON said that she was not sure why Resident #8's room change did not take effect until the morning after the incident, (10/20/16), and that Resident #8 slept in the sunroom, when he/she returned from the hospital and Resident #11 returned to the room. The DON said she did not know why the night staff did not facilitate a room change when Resident #8 returned from the hospital. On 10/20/16 at 9:19 A.M., during survey, Surveyor #3 observed Resident #8 being agitated and angry at the nurses station. Nurse #1 said, Okay, I'm making an executive decision and we're going to make the room change now, or words to that effect.

Based on records reviewed and interviews, for one of 24 sampled residents (Resident #6), the facility failed to ensure that staff adequately identified suspected emotional abuse. Findings included: Facility policy titled Abuse Prohibition defined abuse as the wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Resident #6's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 9/1/16, indicated, Resident #6 had moderate cognitive impairment. On 12/13/16, at 8:06 A.M. Nurse #1 reported to Surveyor #5 that Resident #6 had been observed at 7 A.M. by the on-coming 7-3 shift staff, to be tied to her/his wheelchair with a bed sheet. Nurse #1 said she was concerned that nothing had been done because when she asked the Director of Nursing (DNS), the DNS said she had taken care of it or words to that effect, Nurse #1 observed the accused Certified Nurses Aide (CNA) back at work the next day. CNA #2 was interviewed at 12:35 P.M., on 12/5/16. CNA #2 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 11/24/16 and ending on 11/25/16. CNA #2 said Resident #6 was restless and agitated throughout the shift and refused to stay in bed so she was kept in her/his wheelchair for safety. CNA #2 said that around 5 A.M. she had to provide care to other residents and she didn't know what to do with Resident #6, so she tied her/him to her/his wheelchair with a bed sheet and left her/him in her/his room. CNA #2 said that the Resident was so agitated that she/he tried to fight with her but she felt that it was more important to keep her/him safe so she did it anyway for safety. CNA #2 also said that she forgot to remove the sheet before the end of her shift. CNA #2 said that I used to do that when I worked at another nursing home and we did it but the DNS here said never again or words to that effect. CNA #3 was interviewed at 12:05 P.M., on 12/13/16. CNA #3 said when she reported to the unit at 7:00 A.M., on 11/25/16, the CNA that was assigned to Resident #6 during the 7 A.M. - 3 P.M. shift asked her to come into Resident #6's room and see what she had found. CNA #3 said that upon entering Resident #6's room she observed Resident #6 tied to her/his wheelchair with a bed sheet, naked from the waist up with her/his top on the floor. CNA #3 said she had never seen anything like this before and it upset her a lot. CNA #3 also said that they do not use sheets to restrain anyone and in order to restrain someone you had to have a doctor's order first. CNA #4 was interviewed at 3:40 P.M., on 12/13/16. CNA #4 said, at the beginning of her shift, around 7:00 A.M., on 11/25/16, she witnessed Resident #6 in his/her wheelchair naked from the waist up, tied to her/his wheelchair with a bed sheet. She said that the CNA who had called her in to witness the Resident asked her to get the nurse so she did. Surveyor #5 placed several calls to the phone number given by the facility to contact the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. The Administrator and Nurse #4 (who was the Director of Nursing at the time of the incident) were interviewed on 12/13/2016, at 9:55 A.M. Nurse #4 said that Resident #6 did not have an order for [REDACTED].- 3 P.M. nurse informed her of the incident on 11/25/2016. Nurse #4 said she interviewed CNA #2 the same day and CNA #2 told her she did it because she was afraid the Resident would fall. The Administrator said that although it was not a good choice the CNA made, neither he nor the DNS at the time (Nurse #4) believed it constituted abuse because the CNA's heart was in the right place and Resident #6 did not suffer any ill effects as a result of being tied to her wheelchair and left alone in her/his room because she/he is cognitively impaired and didn't remember anything. The Administrator also said that he did not report it to the state agency because their investigation had concluded that no abuse had occurred. Review of the facility document titled Investigation Summary and dated 11/25/2016, indicated that under Section III. labeled Summary of Investigation, no conclusion to the investigation is documented.

Based on documentation review and staff interview, the facility failed to thoroughly investigate and report to the State Survey Agency an allegation of abuse for 1 resident, (Resident #6) in a total sample of 24 residents as required by the facility's abuse policy and State and Federal law. Facility policy titled Physical Restraints Review Procedures indicates that prior to applying a restraint the following must take place: *alternatives to restraint use are tried first *complete a restraint assessment for least restrictive device *obtain a Physicians order *obtain informed consent from resident or responsible party *care plan should reflect current restraint use Facility policy titled Abuse Prohibition defined abuse as the wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Resident #6's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 9/1/16, indicated, Resident #6 had moderate cognitive impairment. On 12/13/16, at 8:06 A.M. Nurse #1 reported to Surveyor #5 that Resident #6 had been observed at 7 A.M. by the on-coming 7-3 shift staff, to be tied to her/his wheelchair with a bed sheet. Nurse #1 said she was concerned that nothing had been done because when she asked the Director of Nursing (DNS), the DNS said she had taken care of it or words to that effect, Nurse #1 observed the accused Certified Nurses Aide (CNA) back at work the next day. CNA #2 was interviewed at 12:35 P.M., on 12/5/16. CNA #2 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 11/24/16 and ending on 11/25/16. CNA #2 said Resident #6 was restless and agitated throughout the shift and refused to stay in bed so she was kept in her/his wheelchair for safety. CNA #2 said that around 5 A.M. she had to provide care to other residents and she didn't know what to do with Resident #6, so she tied her/him to her/his wheelchair with a bed sheet and left her/him in her/his room. CNA #2 said that the Resident was so agitated that she/he tried to fight with her but she felt that it was more important to keep her/him safe so she did it anyway for safety. CNA #2 also said that she forgot to remove the sheet before the end of her shift. CNA #2 said that I used to do that when I worked at another nursing home and we did it but the DNS here said never again or words to that effect. CNA #3 was interviewed at 12:05 P.M., on 12/13/16. CNA #3 said when she reported to the unit at 7:00 A.M., on 11/25/16, the CNA that was assigned to Resident #6 during the 7 A.M. - 3 P.M. shift asked her to come into Resident #6's room and see what she had found. CNA #3 said that upon entering Resident #6's room she observed Resident #6 tied to her/his wheelchair with a bed sheet, naked from the waist up with her/his top on the floor. CNA #3 said she had never seen anything like this before and it upset her a lot. CNA #3 also said that they do not use sheets to restrain anyone and in order to restrain someone you had to have a doctor's order first. CNA #4 was interviewed at 3:40 P.M., on 12/13/16. CNA #4 said, at the beginning of her shift, around 7:00 A.M., on 11/25/16, she witnessed Resident #6 in his/her wheelchair naked from the waist up, tied to her/his wheelchair with a bed sheet. She said that the CNA who had called her in to witness the Resident asked her to get the nurse so she did. Surveyor #5 placed several calls to the phone number given by the facility to contact the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. The Administrator and Nurse #4 (who was the Director of Nursing at the time of the incident) were interviewed on 12/13/2016, at 9:55 A.M. Nurse #4 said that Resident #6 did not have an order for [REDACTED].- 3 P.M. nurse informed her of the incident on 11/25/2016. Nurse #4 said she interviewed CNA #2 the same day and CNA #2 told her she did it because she was afraid the Resident would fall. The Administrator said that although it was not a good choice the CNA made, neither he nor the DNS at the time (Nurse #4) believed it constituted abuse because the CNA's heart was in the right place and Resident #6 did not suffer any ill effects as a result of being tied to her wheelchair and left alone in her/his room because she/he is cognitively impaired and didn't remember anything. The Administrator also said that he did not report it to the state agency because their investigation had concluded that no abuse had occurred. Review of the facility document titled Investigation Summary and dated 11/25/2016, indicated that under Section III. labeled Summary of Investigation, no conclusion to the investigation is documented.

Based on interviews and records reviewed, for 1 of 24 sampled residents (Resident #6), the Facility failed to ensure that Resident #6 remained free from restraints imposed for convenience of staff. Sometime in the early morning on 11/25/16, CNA #2 restrained Resident #6 to his/her wheelchair by securing a bed sheet around Resident #6's waist and each wheel of the wheelchair, to prevent Resident #6 from getting out of the wheelchair. Findings include: Reveiw of the Facility policy titled Physical Restraints Review Procedures indicates that prior to applying a restraint the following must take place: *alternatives to restraint use are tried first *complete a restraint assessment for least restrictive device *obtain a Physicians order *obtain informed consent from resident or responsible party *care plan should reflect current restraint use Facility policy titled Abuse Prohibition defined abuse as the wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Resident #6's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 9/1/16, indicated Resident #6 had moderate cognitive impairment. On 12/13/16, at 8:06 A.M. Nurse #1 reported to Surveyor #5 that Resident #6 had been observed at 7 A.M. by the on-coming 7-3 shift staff, to be tied to her/his wheelchair with a bed sheet. Nurse #1 said she was concerned that nothing had been done because when she asked the Director of Nursing (DNS), the DNS said she had taken care of it or words to that effect. Nurse #1 observed the accused Certified Nurses Aide (CNA) back at work the next day. CNA #2 was interviewed at 12:35 P.M., on 12/5/16. CNA #2 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 11/24/16 and ending on 11/25/16. CNA #2 said Resident #6 was restless and agitated throughout the shift and refused to stay in bed so she was kept in her/his wheelchair for safety. CNA #2 said that around 5 A.M. she had to provide care to other residents and she didn't know what to do with Resident #6, so she tied her/him to her/his wheelchair with a bed sheet and left her/him in her/his room. CNA #2 said that the Resident was so agitated that she/he tried to fight with her but she felt that it was more important to keep her/him safe so she did it anyway for safety. CNA #2 also said that she forgot to remove the sheet before the end of her shift. CNA #2 said that I used to do that when I worked at another nursing home and we did it but the DNS here said never again or words to that effect. CNA #3 was interviewed at 12:05 P.M., on 12/13/16. CNA #3 said when she reported to the unit at 7:00 A.M., on 11/25/16, the CNA that was assigned to Resident #6 during the 7 A.M. - 3 P.M. shift asked her to come into Resident #6's room and see what she had found. CNA #3 said that upon entering Resident #6's room she observed Resident #6 tied to her/his wheelchair with a bed sheet, naked from the waist up with her/his top on the floor. CNA #3 said she had never seen anything like this before and it upset her a lot. CNA #3 also said that they do not use sheets to restrain anyone and in order to restrain someone you had to have a doctor's order first. CNA #4 was interviewed at 3:40 P.M., on 12/13/16. CNA #4 said at the beginning of her shift, around 7:00 A.M., on 11/25/16, she witnessed Resident #6 in his/her wheelchair naked from the waist up, tied to her/his wheelchair with a bed sheet. She said that the CNA who had called her in to witness the Resident asked her to get the nurse so she did. Surveyor #5 placed several calls to the phone number given by the facility to contact the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. The Administrator and Nurse #4 (who was the Director of Nursing at the time of the incident) were interviewed on 12/13/2016, at 9:55 A.M. Nurse #4 said that she had placed a call to the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. Nurse #4 said that Resident #6 did not have an order for [REDACTED].- 3 P.M. nurse informed her of the incident on 11/25/2016. Nurse #4 said she interviewed CNA #2 the same day and CNA #2 told her she did it because she was afraid the Resident would fall. The Administrator said that although it was not a good choice the CNA made, neither he nor the DNS at the time (Nurse #4) believed it constituted abuse because the CNA's heart was in the right place and Resident #6 did not suffer any ill effects as a result of being tied to her wheelchair and left alone in her/his room because she/he is cognitively impaired and didn't remember anything. Review of the facility document titled Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, dated 9/7/2016, indicated that This presumes that instances of abuse of all residents even those in a coma, cause physical harm, or pain, or mental anguish. Resident #6 was unable to be interviewed, due to cognitive loss, therefore, he/she was unable to express emotional harm from having been restrained to his/her wheelchair, however, a reasonable person would have suffered emotional harm and upset from being restrained in this manner and circumstances.

Based on interviews and records reviewed, for 1 out of 24 sampled residents (Resident #6) the Facility failed to ensure that Resident #6 remained free from restraints imposed for convenience of staff. Sometime in the early morning on 11/25/16, CNA #2 restrained Resident #6 to his/her wheelchair by securing a bed sheet around the Resident's waist and tied each end to the wheels of her/his wheelchair to prevent Resident #6 from getting out of the wheelchair. Findings include: Reveiw of the Facility policy titled Physical Restraints Review Procedures indicates that prior to applying a restraint the following must take place: *alternatives to restraint use are tried first *complete a restraint assessment for least restrictive device *obtain a Physicians order *obtain informed consent from resident or responsible party *care plan should reflect current restraint use Resident #6's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 9/1/16, indicated Resident #6 had moderate cognitive impairment. On 12/13/16, at 8:06 A.M. Nurse #1 reported to Surveyor #5 that Resident #6 had been observed at 7 A.M. by the on-coming 7-3 shift staff, to be tied to her/his wheelchair with a bed sheet. Nurse #1 said she was concerned that nothing had been done because when she asked the Director of Nursing (DNS), the DNS said she had taken care of it or words to that effect. Nurse #1 observed the accused Certified Nurses Aide (CNA) back at work the next day. CNA #2 was interviewed at 12:35 P.M., on 12/5/16. CNA #2 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 11/24/16 and ending on 11/25/16. CNA #2 said Resident #6 was restless and agitated throughout the shift and refused to stay in bed so she was kept in her/his wheelchair for safety. CNA #2 said that around 5 A.M. she had to provide care to other residents and she didn't know what to do with Resident #6, so she tied her/him to her/his wheelchair with a bed sheet and left her/him in her/his room. CNA #2 said that the Resident was so agitated that she/he tried to fight with her but she felt that it was more important to keep her/him safe so she did it anyway for safety. CNA #2 also said that she forgot to remove the sheet before the end of her shift. CNA #2 said that I used to do that when I worked at another nursing home and we did it but the DNS here said never again or words to that effect. CNA #3 was interviewed at 12:05 P.M., on 12/13/16. CNA #3 said when she reported to the unit at 7:00 A.M., on 11/25/16, the CNA that was assigned to Resident #6 during the 7 A.M. - 3 P.M. shift asked her to come into Resident #6's room and see what she had found. CNA #3 said that upon entering Resident #6's room she observed Resident #6 tied to her/his wheelchair with a bed sheet, naked from the waist up with her/his top on the floor. CNA #3 said she had never seen anything like this before and it upset her a lot. CNA #3 also said that they do not use sheets to restrain anyone and in order to restrain someone you had to have a doctor's order first. CNA #4 was interviewed at 3:40 P.M., on 12/13/16. CNA #4 said at the beginning of her shift, around 7:00 A.M., on 11/25/16, she witnessed Resident #6 in his/her wheelchair naked from the waist up, tied to her/his wheelchair with a bed sheet. She said that the CNA who had called her in to witness the Resident asked her to get the nurse so she did. Surveyor #5 placed several calls to the phone number given by the facility to contact the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. The Administrator and Nurse #4 (who was the Director of Nursing at the time of the incident) were interviewed on 12/13/2016, at 9:55 A.M. Nurse #4 said that she had placed a call to the agency nurse who had worked the 11 P.M.-7 A.M. shift that the incident had occurred but was unable to reach her. Nurse #4 said that Resident #6 did not have an order for [REDACTED]. Resident #1 was unable to be interviewed, due to cognitive loss, therefore, he/she was unable to express emotional harm from having been restrained to his/her wheelchair, however, a reasonable person would have suffered emotional harm and upset from being restrained in this manner and circumstances.

Based on observation, record review, and staff interviews, the facility failed to prevent the progression of a pressure sore for 1 resident (Resident #10) from a total sample of 18 residents. The facility failed to ensure that the resident received the necessary treatment and services to promote healing when the pressure sore was first observed. Findings include: Despite providing total care for bathing, dressing and incontinent care as well as positioning every 2 hours, the facility failed to identify the worsening of a Stage 1 pressure area on the coccyx until the area was identified as unstageable during survey observation on 11/12/15. Additionally, there was evidence of several deep tissue injuries (Purple or maroon discolored intact skin due to damaged of underlying soft tissue with depth of damage unknown). Review of the resident's quarterly Minimum Data Set(MDS) a assessment, dated 8/10/15, indicated that the resident required extensive assistance for bed mobility and transfers. The MDS indicated that the resident was non-ambulatory, required a mechanical lift for all transfers, was dependent for his/her activities of daily living (ADLs) and was incontinent of bowel and bladder. The MDS indicated that the resident was at risk for developing pressure sores; however, no pressure sores were present during the assessment reference period. Review of the resident's clinical record on 11/10/15 indicated that the resident was readmitted to the facility on [DATE] from an acute hospitalization . The resident's [DIAGNOSES REDACTED]. Review of the resident's Norton Plus Pressure Ulcer Scale, dated 10/31/15, indicated that the resident was at high risk for skin breakdown. Review of the 10/31/15 Clinical Health Status Admission Record, section B indicated, skin concern #1 was documented as bilateral heels with deep tissue wounds, first observed 10/31/15; skin concern #2 indicated, coccyx, red. Review of the nurse progress note dated 10/31/15 @ 14:46 (2:46 P.M.), indicated Resident returned from the hospital at approximately 2:00 P.M. today, 10/31/15. Resident has not spoke, skin check revealed deep tissue wounds to BL (bilateral) heels. Coccyx is red, intact . The Treatment Administration Record (TAR) and the monthly physician orders for 11/1/15 through 11/30/15 indicated: * Wash both heels with normal saline (NS), pat dry, and apply Vaseline gauze with protective dressing every day shift. * Keep pressure off heels every shift. * Weekly skin assessment. Document in skin book. There were no physician orders addressing the coccyx stage one pressure sore. There was no evidence of documentation on the TAR or in the nurses' progress note from 11/1/15 regarding the condition of the resident's buttocks and coccyx. A plan of care was developed for Resident is at risk for pressure ulcer due to incontinence, pain, cognitive loss, decreased motivation, decreased mobility and decreased ROM, use of psych. medication, renal and [MEDICAL CONDITION], and newly admitted , dated 11/3/15, with a goal that the Resident's skin will remain intact. Interventions included the following: * Complete pressure ulcer risk assessment as per protocol. * Complete skin assessment as per protocol. * Conduct skin inspection as per protocol. * Do not massage over bony prominence's. * Encourager him/her to use toilet or commode at regular intervals to prevent incontinence. * Float heels. * Provide nutritional and hydration support. * Provide pressure reducing wheelchair cushion. * Provide pressure reduction/relieving mattress. * Provide skin care after incontinent episodes and apply barrier cream as per protocol. * Refer to therapy. * Reposition every 2 hours. Observations by Surveyor #1, Surveyor #2, and Surveyor #3 with the Director of Nurses (DON) present on 11/12/15 at 10:10 A.M., revealed an unstageable pressure sore to the coccyx that measured approximately 8 centimeters (cm) by 2 cm with an area of approximately 0.5 cm by 0.5 cm of slough in the center. The left buttock was intact with 7 irregular shaped discolored purple/red areas (deep tissue injury). These 7 areas measured approximately 0.5 cm by 1 cm each, incorporated into a 6 cm by 4.5 cm reddened area. The right buttocks had 3 stage 1 areas which were red, raised and skin intact. During interview on 11/12/14 at 10:10 A.M. with the DON, she said she was unaware that there was any pressure sores on Resident #10's coccyx and buttocks. She said there was no physician order to treat the area and she would immediately obtain an air mattress (as the pressure relief mattress on the bed was not an air mattress) and notify the physician of the resident's condition. The facility failed to provide the resident with effective interventions to prevent the worsening of the resident's coccyx and bilateral buttocks.

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 Resident (#5) in an original sample of 19 Residents and an expanded sample of 2 Residents. Findings include: 1. The facility failed to provide the necessary care and services for the prevention and treatment of [REDACTED]. Resident #5 was admitted to the nursing facility in July 2013 with [DIAGNOSES REDACTED]. The Discharge note from the Acute Care setting, dated 7/24/13, documents that pathology reports for the lung mass were negative. The summary of the acute care stay, dated 7/24/13, documents that the Resident complained of chronic bilateral hip pain at a rating of 8 out of 10 (on a scale of 1 to 10 with 1 being mild pain and 10 being excruciating pain). The Resident had originally been prescribed [MEDICATION NAME] 10 milligrams every 4 hours as needed (PRN). However, the hospital found the Resident to be over sedated and negotiated with the Resident a dosage of [MEDICATION NAME] 10 milligrams three times daily. An orthopedic followup was scheduled for 8/5/13 at the hospital. A Nurse Practitioner note, dated 7/31/13, documents that the Resident requested an extra pain pill at night. The note documents that the Resident reported waking up at night cranky and with cold sweats. Nurse Practitioner #1 documents that the Resident knows the physician's agreement for pain medication three times daily (scheduled for 7:00 A.M., 1:00 P.M. and 7:00 P.M.) and that the Resident needed to follow up with the Orthopedics or pain clinic for pain medication per the physician. Resident #5 went for an Orthopedic workup on 8/5/13. The Physical Therapy Department sent a hand written note with Resident #5 documenting minimal progress with Physical Therapy with a 10 out of 10 pain rating secondary to reports of significant [MEDICAL CONDITION]. The note documents that the Resident had received E-Stim treatment and hot packs with minimal results. The note asks the Orthopedic Physician if the Resident is a candidate for surgery on both hips. The Orthopedic physician responded to this note that the Resident is a candidate for total hip replacement and also requests that the facility "please consider a night time dose of pain medication as patient is unable to sleep due to hip pain." The Resident is scheduled for a follow up appointment with the Orthopedic physician on 8/13/13. A Physician's progress note, dated 8/7/13 documents that the Resident again, asked for a night time dose of pain medication, reporting poor sleep secondary to pain in the hips. The note further documents that the Resident saw an Orthopedic Physician on 8/5/13 and that the Resident stated that the Orthopedic Physician concurred with the Resident. The Physician documents that it is a hand written note which is in the chart "?? from whom, no note from M.D. (medical doctor)." The physician documents that the Resident was encouraged to change providers if he/she was unhappy with his/her care. On 8/9/13, the Physician again saw the Resident and documents that the Resident continued to request more pain medication and has been threatening to call the State or sueing the Physician if the Physician does not prescribe what the Resident wants. The progress note further documents that the [MEDICAL CONDITION] is moderate at worst on x-ray and that a physical exam does not substantiate the subjective reporting of severe pain. The Physician documents that he told the Resident that blackmail is not appropriate and that the Physician would consider reporting the Resident to the D.E.A. (Drug Enforcement Administration) An Orthopedic Surgeon report, along with x-ray reports, dated 8/5/13 and sent to the facility on [DATE] documents severe arthropathy of the hips bilaterally, possible secondary to avascular necrosis (lack of blood flow to the bone causing bone tissue destruction). The x-ray reports document that the joint spaces are narrowed to the point of bone-on-bone articulation. Interview with Resident #5 on 8/19/13 at 11:00 A.M. revealed that the Resident received [MEDICATION NAME] at 7:00 A.M., 1:00 P.M. and 7:00 P.M. (every 6 hours). Resident #5 stated that he/she often woke up during the night with a pain level which was "off the charts". Resident #5 stated that he/she had not selected his/her physician on admission and had asked for a change in physicians. Review of the clinical record on 8/20/13 revealed that the Resident had a physician's orders [REDACTED]. Resident #5 was observed lying in bed on 8/20/13 at 12:45 P.M. The Resident stated he/she was not having a good day and that the pain was excruciating. The Resident was observed to grimace with any movement in the bed. Resident #5 was asked if he/she was aware that there was a physician's orders [REDACTED]. Resident #5 stated that no one had told him/her nor had it been offered. Charge Nurse #2 was asked on 8/20/13 at 1:00 P.M. about the Physician order [REDACTED]. Medication Nurse #1 was asked to check the medication cart for the [MEDICATION NAME]. After looking in each draw of 2 medication carts, Medication Nurse #1 stated that there was no [MEDICATION NAME] on the unit. The Director of Nurses came on to the B unit and stated that the medical supplies person had a "secret stash" of [MEDICATION NAME] which he/she would be bringing to the unit. When asked to show this Surveyor the supply of [MEDICATION NAME], it was discovered that the [MEDICATION NAME] was not available in the building and that the medical supply person had been sent to the local CVS pharmacy for the topical medication. Review of the medication administration records for July 2013 and August 2013 revealed that the Resident had not been administered the [MEDICATION NAME] gel. Review of the progress notes revealed that there was no documentation of the [MEDICATION NAME] being offered to this Resident. On 8/21/13, at 12:30 P.M., Resident #5 was asked about his/her pain. The Resident was asked to use a pain scale of 1 to 10 (with one being the least amount of pain and 10 being excruciating pain) to rate his/her pain level. Resident #5 stated that his/her pain level was "off the charts". After receiving the scheduled [MEDICATION NAME], the pain was still "off the charts" but more bearable. When asked to rate the pain this Resident experienced during the night, the Resident stated "it's oh my God, somebody please help me" level of pain. Interview with the Director of Nurses' on 8/21/13 at 2:00 P.M. revealed that she was unaware that the Resident was not receiving the [MEDICATION NAME] gel. The Director of Nurses stated that the physician had stated that the Resident's [MEDICAL CONDITION] was mild per the Orthopedic exam and x-rays (and not severe with bone on bone per the report). The Director of Nurses stated that she had not reviewed the reports from the Orthopedic Surgeon. On 8/22/13 at 12:45 P.M. Resident #5 was observed approaching a CNA #4 and asking for his/her pain medication. CNA #4 responded that everyone was "really busy right now." As the Resident self propelled his/her wheelchair down the hall, CNA #4 was overheard stating "pain, pain, pain, he/she is always complaining about pain." CNA #4 was observed to go into the dining room without reporting the Resident's complaint of pain.