Every finding on record at Mill Brook Rehabilitation and Healthcare Center

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen walk-in refrigerator was maintained in a sanitary and safe condition. Findings include:1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's policy titled Sanitization, revised November 2022, indicated but was not limited to the following:-The food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation:-All kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. -All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. On 8/25/25 at 8:00 A.M. and on 8/28/25 at 11:14 A.M., the surveyor observed in the walk-in refrigerator:-shelving with several areas of rust;-shelving with extensive patchy areas of raised yellow, powdery substance;-black powdery buildup on the walk-in refrigerator wall inches away from raw onions stored in a mesh bag;-debris and spillage underneath shelving including brown and black colored spillage underneath an area of shelving that contained raw meat and/or poultry;-debris and black buildup along the perimeter and in the corners of the floor. During an interview on 8/28/25 at 2:27 P.M., the Food Service Director (FSD) and surveyor observed the shelving and floor in the walk-in refrigerator. The FSD said the walk-in refrigerator should be kept in a clean and sanitary condition.

Based on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#16 and #5), out of a total sample of 27 residents.Specifically, the facility failed:1. For Resident #16, to ensure the April 2025 and May 2025 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to assess the need for Meclizine (an anticholinergic medication used to treat nausea, vomiting and dizziness) and to obtain an A1c (blood test that measures an average blood sugar level over a period of two to three months); and2. For Resident #5, to ensure the April 2025, May 2025, and July 2025 consultant pharmacist recommendations were maintained as part of the permanent medical records and acted upon timely to sequence multiple as needed pain medications and to obtain labs related to specific medication use.Findings include:Review of the facility's policy titled Pharmacy Services-Role of the Consultant Pharmacist, revised April 2019, indicated but was not limited to the following: -The consultant pharmacist will provide specific activities related to medication regimen including: -a documented review of the medication regime of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; -appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated; -providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review 1. Resident #16 was admitted to the facility in April 2021 with diagnoses including type 2 diabetes mellitus, hypertension, and major depression disorder. Review of the medical record indicated the consultant pharmacist made recommendations for Resident #16 in April 2025 and May 2025 and generated a report to be acted upon and reported to the physician, however, the surveyor was unable to locate either the 4/28/25 or the 5/30/25 MRR report in the Resident's medical record. During an interview on 8/27/25 at 10:59 A.M., Nurse #3 and the surveyor reviewed Resident #16’s medical record and could not locate the MRR reports for April 2025 or May 2025. Nurse #3 said she was not sure how the pharmacy recommendations were addressed. Nurse #3 said she believed the Unit Managers (UM) took care of them. On 8/27/25 at 11:30 A.M., the Director of Nursing (DON) provided the surveyor with a printed copy of the April and May reports. Review of the 3/15/25 Consultant Pharmacist Recommendations to Prescriber report for Resident #16 indicated the following recommendation: -Pt is currently receiving Meclizine which is a highly anticholinergic medication. Please consider discontinuing or re-evaluating for necessity. Meclizine is also on the Beer’s list. Review of the current Physician’s Orders included the following medication: -Meclizine HCL oral tablet 12.5 milligrams (MG) give 12.5 MG by mouth every 12 hours as needed for dizziness, dated 2/26/24. Further review of the medical record failed to indicate the physician addressed the consultant pharmacist's recommendation by discontinuing or documenting the necessity for the use of Meclizine. Review of the 5/30/25 Consultant Pharmacist Recommendations to Prescriber report for Resident #16 indicated the following recommendation: -The following are labs recommended to upload for monitoring the patient’s medication treatment as well as the recommended minimum collection frequency: -Antidiabetic meds: A1C q3m -If unavailable, please consider ordering the labs. Review of current Physician's Orders included the following medications: -Insulin Glargine Subcutaneous Solution 100 Unit/milliliter (ML) (insulin Glargine) Inject 65 units subcutaneously in the morning related to type 2 diabetes mellitus with hyperglycemia, dated 5/24/2025 -Insulin Glargine Subcutaneous Solution 100 Unit/ML (insulin Glargine) Inject 10 units subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia, dated 5/24/2025 -Novolog Solution 100 Unit/ML (Insulin Aspart) inject as per sliding scale: -if 150-199 give 4 units subcutaneously -200-249 give 6 units subcutaneously -250-299 give 8 units subcutaneously -300-349 give 10 units subcutaneously -350-399 give 12 units subcutaneously -400-499 give 14 units subcutaneously before meals for diabetes. Notify MD if blood sugar less than 70 or greater than 450 dated 8/26/25 -Metformin Tablet 500 milligrams (mg) give one tablet orally two times a day for diabetes Review of the laboratory reports noted an A1c was last collected on 2/21/25. The A1c results flagged high at 7.9 out of a reference range of 4.1-6.0. Further review of the medical record failed to indicate the physician addressed the consultant pharmacist's recommendation by ordering an A1c every 3 months. During an interview on 8/28/25 at 9:49 A.M., UM #1 reviewed the April and May pharmacy recommendations. The UM said the reports were usually e-mailed to her and she would print out and give them to the physician to address the recommendations. The UM said she would then in return review the recommendations and make any needed changes in the resident’s medical record. The recommendations were then scanned into the resident’s medical record. The UM said the pharmacy recommendations from April and May were not addressed. The UM said that the facility had switched to a new pharmacy around May 2025. The UM said she had not received any recommendations by e-mail during the transition. The UM said she had informed the DON, and she had started to receive the pharmacy recommendations in June. During an interview on 8/28/25 at 1:00 P.M., the DON said she did not keep copies of the pharmacy recommendations. The DON said the Unit Managers were responsible for making sure pharmacy recommendations were reviewed and completed by the physicians. The DON said the recommendations should have been addressed but were missed with the changeover in pharmacies. 2. Resident #5 was admitted to the facility in February 2025 with diagnoses which included artificial knee joint, morbid obesity, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment, dated 8/1/25, indicated Resident #5 was administered an antipsychotic medication. Review of the medical record indicated the consultant pharmacist made recommendations for Resident #5 in April 2025 and May 2025 and generated a report to be acted upon and reported to the physician, however, the surveyor was unable to locate either the 4/29/25 or the 5/30/25 MRR report in the Resident's medical record. On 8/28/25 at approximately 10:30 A.M., the DON provided the surveyor with a printed copy of the April and May reports. Both reports were unsigned by the provider. Review of the MRR, dated 4/29/25, indicated Resident #5 was taking multiple as needed (PRN) pain medications requiring sequencing, which is typically done by assigning intensity of pain to each agent. Please consider providing pain scales or severities within the order to provide direction for administration. Acetaminophen (APAP) and Hydrocodone-APAP. Review of the MRR, dated 5/30/25, indicated labs were recommended to upload for monitoring of the patient's medication treatment as well as the recommended minimum collection frequency. Antipsychotics: Lipids every 12 months and Allopurinol/Uloric: uric acid level annually. If unavailable, please consider ordering the labs. Review of the medical record failed to indicate the pain medications were sequenced, failed to indicate the requested labs were ordered, and failed to indicate the recommendations were reviewed and declined by the provider. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said the Unit Managers handle the pharmacy recommendations. During an interview on 8/28/25 at 1:03 P.M., UM #1 said the pharmacy recommendations go to all the UMs, and we get them to the providers. She said there was an issue in the spring and for some reason she was not getting them, so they were not done. During an interview on 8/28/25 at 2:09 P.M., the DON said all the pharmacy recommendations should be addressed within the month. She said they did not keep the forms once the orders were written all the time, but she should. She said she was unaware the recommendations from April and May were never addressed.

Based on record review and interview, the facility failed to ensure one Resident (#46), out of a total sample of 27 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure Wound Physician recommendations were addressed and implemented timely. Findings include: Review of the facility's policy titled Pressure Ulcer /Skin Breakdown - Clinical Protocol, dated as last revised 3/2014, indicated but was not limited to the following:-The physician will authorize pertinent orders related to wound treatments.-The physician will help identify medical interventions related to wound management. Review of the facility's policy titled Consultant Physician Services, dated as adopted 2/2023, indicated but was not limited to the following:-Consultant physician services are available to the residents as ordered by their attending physician or physician designee.-After completion of the consult, the consultant physician will provide the facility with a consultation report which shall include any orders, recommendations, or follow up actions.-The resident's attending physician should be informed of the recommendations, treatments, diagnostics, and medications ordered by the consultant.-Orders from the consultant physician will be entered in the resident's medical record. Review of the facility's contract with the Wound Physician, dated 3/12/25, effective 4/1/25, indicated but was not limited to the following:-Facility Responsibilities: The facility agrees to support delivery of wound care services and commits to inform the resident's primary care provider of the Provider's recommendations within 24 hours. Resident #46 was admitted to the facility in May 2025 with diagnoses which included a displaced left femur fracture, diabetes mellitus, history of falls, and abnormal gait/mobility. Review of the Minimum Data Set (MDS) assessment, dated 8/27/25, indicated Resident #46 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Additionally, he/she was a risk for pressure ulcers, and had one unhealed unstageable pressure injury (pressure injury where the depth of tissue damage cannot be determined due to the presence of slough (yellow/green/grey dead tissue) or eschar (thick, leathery layer of dead tissue) covering the wound bed). Review of the medical record, including nursing progress notes, indicated the pressure ulcer was observed on 6/8/25, the Nurse Practitioner (NP) was notified and a treatment ordered. Review of the Initial Wound Evaluation and Management Summary, dated 6/19/25, indicated but was not limited to the following:-Site 2: Unstageable Deep Tissue Injury (DTI- purple/maroon discoloration due to prolonged pressure) of the left medial heel, measuring 4 x 5.5 centimeters (cm), intact blood-filled purple/maroon discoloration. Recommended treatment was skin prep (breathable protective film like barrier) once daily. Review of the Physician's Orders indicated but were not limited to the following:-Apply skin prep to left heel every day shift for wound care. (6/17/25) Review of the Wound Evaluation and Management Summary, dated 8/7/25, indicated but was not limited to the following:-Site 2: Unstageable (due to necrosis-dead cells or tissues) of the left medial heel, measuring 2.5 x 2.1 cm x depth not measurable due to presence of non-viable tissue and necrosis. Thick adherent devitalized necrotic tissue 100%, Wound progress not at goal. Recommended treatment skin prep peri wound, Apply collagen sheet (gel sheet to maintain a moist wound environment), calcium alginate (highly absorbent/promotes moist healing environment), and Santyl (wound gel to debride necrotic tissue) followed by gauze island dressing once daily. Review of the physician's orders indicated the wound care order was not implemented until 8/12/25 (five days after he/she was seen by the wound care physician). Review of the Wound Evaluation and Management Summary, dated 8/21/25, indicated but was not limited to the following:-Site 2: Unstageable (due to necrosis) of the left medial heel, measuring 2 x 2 cm x depth not measurable due to tissue overgrowth. Recommended treatment skin prep peri wound, Apply collagen sheet and calcium alginate followed by gauze island dressing once daily. Review of the physician's orders indicated the wound care order was not implemented until 8/26/25 (five days after he/she was seen by the wound care physician. Review of the nursing and physician progress notes failed to indicate the provider was notified the next day of the consultant's recommendations and did not want the order changed at that time. Further review of the physician's progress note, dated 8/21/25, indicated Resident #46 was followed by the wound physician for the decubitus ulcer on the left heel and they agree with all recs. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said Unit Manager (UM) #1 already did wound rounds with the wound physician earlier this morning. She said UM #1 usually is not here on Thursdays, so UM #2 or a desk nurse will do rounds. She said they handle writing all the orders and she has nothing to do with wound rounds; the new orders just appear in the computer. During an interview on 8/28/25 at 1:03 P.M., UM #1 said she did rounds today, but normally she is off on Thursdays. She said the wound notes typically import to the electronic medical record late afternoon and the orders should be put into the computer by the next day. She said rounds used to be on Friday, but by the time the notes were imported, the orders were not getting entered until Monday, so we switched wound rounds to Thursdays, so we could get the ordered entered the next day. She said normally UM #2 does rounds with the doctor on Thursday and then Friday she would write all the orders, complete the assessments, evals, and progress notes. She said when she is off, as far as she knows there is not someone assigned to ensure the orders are written. She said that is why there was a delay with the 8/7/25 and 8/21/25 recommendations getting entered. She said typically no one covers if she takes a few days off, so her work sits there until she returns. During an interview on 8/28/25 at 2:09 P.M., the Director of Nurses (DON) said wound rounds are done on Thursdays and if the recommendations are uploaded early enough, they should be reviewed that day, if not the next day. She said if the UM is off, the expectation is the floor nurses would ensure the orders were written, but there was not a specific person assigned to ensure they were complete. When asked how a floor nurse would know if orders needed to be obtained and written she said, they might have to work on that process.

Based on record review and interview, the facility failed to ensure one Resident (#46), out of 27 sampled residents, and one Resident (#159), out of three closed records, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed:1. For Resident #46, to ensure the Wound Physician's recommendations were addressed and implemented timely for a skin tear; and2. For Resident #159, to: a. Accurately transcribe the physician's order to send Resident #159 to the emergency room for evaluation, resulting in a minimum of a nine-hour delay (6/30/25 5:00 P.M. to 7/1/25 2:00 A.M.) in transferring the Resident to the hospital, and b. Report abnormal urinalysis results to the Physician in a timely manner. Findings include:1. Review of the facility's policy titled Consultant Physician Services, dated as adopted 2/2023, indicated but was not limited to the following: -Consultant physician services are available to the residents as ordered by their attending physician or physician designee. -After completion of the consult, the consultant physician will provide the facility with a consultation report which shall include any orders, recommendations, or follow up actions. -The resident’s attending physician should be informed of the recommendations, treatments, diagnostics, and medications ordered by the consultant. -Orders from the consultant physician will be entered in the resident’s medical record. Review of the facility's contract with the Wound Physician, dated 3/12/25 effective 4/1/25, indicated but was not limited to the following: -Facility Responsibilities: The facility agrees to support delivery of wound care services and commits to inform the resident’s primary care provider of the provider’s recommendations within 24 hours. Resident #46 was admitted to the facility in May 2025 with diagnoses which included a displaced left femur fracture, diabetes mellitus, history of falls, and abnormal gait/mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/27/25, indicated Resident #46 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Additionally, he/she had a skin tear. Review of the medical record including nursing progress notes indicated he/she sustained the skin tear on 6/9/25 and a dressing was applied. Review of the Initial Wound Evaluation and Management Summary, dated 6/19/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 5 centimeters (cm), depth unmeasurable due to tissue overgrowth. Recommended treatment Silver sulfadiazine (topical antibiotic cream) followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Cleanse skin tear to right shin with normal saline (NS), pat dry, apply xeroform (mesh gauze occlusive dressing), followed by an ABD pad and kerlix (gauze roll) every three days for wound care (6/17/25) Review of the physician's orders failed to indicate the wound care recommendation from 6/19/25 was implemented. Review of the Wound Evaluation and Management Summary, dated 6/26/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 4 cm, depth unmeasurable due to non-viable tissue and necrosis (dead cells or tissue). Recommended treatment Silver sulfadiazine, skin prep (breathable protective film like barrier) followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Cleanse skin tear to right shin with normal saline (NS), pat dry, apply xeroform, followed by an ABD pad and kerlix every three days for wound care (started 6/17/25 and discontinued 6/27/25) -Skin tear wound of the right shin, cleanse with NS, pat dry, apply silver sulfadiazine, skin prep border, followed by gauze island with border dressing twice daily (6/30/25) The facility failed to implement the recommendation made on 6/19/25 which was repeated on 6/26/25 until 6/30/25 (11 days later). Additionally, the treatment that was in place was discontinued on 6/27/25 and there was no treatment in place from 6/27/25 through 6/30/25. Review of the Wound Evaluation and Management Summary, dated 7/3/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 5 cm, depth unmeasurable due to dry fibrinous exudate (scab). Wound progress: not at goal. Recommended treatment skin prep daily followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Skin tear wound of the right shin, cleanse with NS, pat dry, apply silver sulfadiazine, skin prep border, followed by gauze island with border dressing twice daily (started 6/30/25 and discontinued 7/8/25). -Skin tear wound of the right shin, cleanse with NS, pat dry, apply skin prep and cover gauze island with border dressing daily (7/9/25) The facility failed to implement the recommendation made on 7/3/25 until 7/9/25 (6 days later). Review of the nursing and physician progress notes failed to indicate the provider was notified the next day of the consultant recommendations and did not want the orders changed at that time. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said the Unit Manager (UM) handles writing all the orders and she has nothing to do with wound rounds; the new orders just appear in the computer. During an interview on 8/28/25 at 1:03 P.M., UM #1 said Resident #46 was on a different unit in June and July, so she could not speak specifically to why those recommendations were not done, however she reviewed the medical record including wound notes, orders, and progress notes and confirmed the orders were not written timely and there were no notes indicating the physician declined the recommendations. During an interview on 8/28/25 at 2:09 P.M., the Director of Nurses (DON) said wound rounds are done on Thursdays and if the recommendations are uploaded early enough, they should be reviewed that day, if not the next day. She said if the UM is off, the expectation is the floor nurses would ensure the orders were written, but there was not a specific person assigned to ensure they were complete. When asked how a floor nurse would know if orders needed to be obtained and written she said, they might have to work on that process. 2. Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, 9324, dated as last revised April 11, 2018, indicated but was not limited to the following:-Licensed nurses accept, verify, transcribe, and implement orders.-Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #159 was admitted to the facility in May 2025 with diagnoses which included: Severe sepsis with septic shock, acute kidney failure, hyponatremia, retention of urine, and generalized edema. Review of the MDS assessment, dated 6/10/25, indicated Resident #159 scored 15 out of 15 on the BIMS, indicating Resident #159 was cognitively intact. Further review of section HO100A indicated he/she had an indwelling catheter. Review of the form titled Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 5/28/25 and signed by Resident #159 indicated he/she wished to be a full code with further directions to transfer to hospital. a. Review of a Social Service note, dated 7/2/25 at 10:09 A.M., indicated Discharge Note-Resident #159 was sent to the Hospital yesterday and admitted with sepsis. Review of Resident #159’s Nursing Progress notes indicated the following:-6/30/25 at 9:29 P.M., Nurse #2 wrote, labs reviewed with Physician #1 order to repeat in the AM. -7/1/25 at 2:40 A.M., Nurse #7 wrote, Lab from 6/30 found with an order from Physician #1 to send to the emergency room for evaluation, discuss with patient that he/she could wait till the morning and discuss with another provider or we could send him/her now as physician recommended this morning, he/she wanted to go. Patient was transferred via ambulance to an outside hospital. Review of the medical record failed to include the 6/30/25 lab slip. During an interview on 8/27/25 at 2:45 P.M., Medical Records Staff #1 said the nurses transcribe the physician order written on the lab slips. She said the nurses can put the lab slips in the shredder bin or put them in the scan folder, and she scans them into the medical record. Medical Record Staff #1 reviewed the electronic medical record and the Blood lab results from 6/29/25 with any physician notation was not in the medical record. During a telephonic interview on 8/27/25 at 4:50 P.M., Physician #1 said he reviewed the labs for Resident #159 and faxed back to the facility to send Resident #159 to the ER for evaluation. He said his instruction was clear. The surveyor requested a copy of the lab results with his written instructions and Physician #1 agreed to send a copy. On 8/27/25 at 4:56 P.M., the surveyor received the lab results with instructions for Resident #159 from Physician #1 on the Cookside Unit fax. Review of the lab results, dated 6/30/25, indicated the following: -Specimen was collected on 6/30/25 at 5:17 A.M. and reported on 6/30/25. -Results indicated multiple abnormal values. -The written instructions from Physician #1 at the bottom of the page indicated: Two arrows pointing at the words ER evaluation. -There were no instructions noted to repeat labs in the morning. -The original fax time stamp printed indicated it was faxed from the Cookside Unit to the physician’s office on 6/30/25 at 1:06 P.M. -Time stamp on the fax from the physician to the surveyor on 8/27/25 matched the actual time surveyor received the fax, 8/27/25 at 4:56 P.M. Review of facility form titled Skilled Nursing Facility to Hospital Transfer Form, dated 7/1/2025, indicated Resident #159 was transferred to the hospital on 7/1/25 at 2:11 A.M., a minimum of 9 hours after the facility would have received the fax from Physician #1’s office. During an interview on 8/27/25 at 4:10 P.M., Nurse #1 said the process is to print the lab results in the morning and for Physician #1, he wants the lab slips faxed over to his office, and he faxes back written instructions on the lab slip. Nurse #1 said once you receive the fax back, you transcribe the order and write a note and then you can shred the written communication, or you can put it in the scan folder. During an interview on 8/27/25 at 4:17 P.M., Nurse #2 said he found Resident #159’s lab slip on the desk and thought the physician’s written instructions said to repeat labs in the A.M. Nurse #2 said he wrote a note to repeat labs in the A.M., and left the lab slip on a pile of other papers. Nurse #2 said the next day, Nurse #7 told him, she sent Resident #159 to the hospital. Nurse #2 said, Nurse #7 told him she saw the lab slip on the desk and knew Physician’s #1’s writing and read the order on the lab slip to send Resident #159 to the hospital. Nurse #2 said the lab slip was sent over during the day shift. Nurse #2 said he interpreted the physician instructions differently than Nurse #7. During an interview on 8/27/25 at 4:58 P.M., Nurse #2 viewed the faxed lab results and said it looks like the physician wrote re-evaluation. He said he can now see the “ER evaluation”. During an interview on 8/28/25 at 7:35 A.M., the DON said the first nurse misread the physician instructions, and the 11-7 nurse who knew the physician better read it as send the Resident to the ER. During an interview on 8/28/25 at 8:30 A.M., with both Physician #1 and the DON present, Physician #1 said if the lab slip was sent to my office at 1:00 P.M, he would have acted upon and returned it to the facility within 1-2 hours. Physician #1 said the lab results were not faxed over to the facility after 5:00 P.M. Physician #1 said he was sending out Resident #159 for low sodium and would not have expected it to be a 911 call but would expect the Resident to go to the hospital within a couple hours. Physician #1 confirmed the written instructions on the lab slip said to send to ER, not repeat labs in the A.M. b. Review of Resident #159’s urinalysis, collected on 6/27/25 and reported to the facility on 6/29/25 at 9:52 A.M., indicated abnormal results with greater than 100,000 CFU/ML of klebsiella pneumonia, ESBL. Review of Nursing Progress notes, dated 6/27/25 at 4:43 A.M., Nurse #7 wrote, Urine obtained. Results pending. Review of Social service note, dated 6/27/25 at 3:34 P.M., this morning, interdisciplinary team discussed Resident #159. Foley was taken out this morning, Lab work ordered to determine fluid restriction and sodium tablets. Review of Nursing progress note, dated 6/30/25 at 3:51 P.M., written by the DON, Resident noted with overall decline, failed voiding trial x 2, noted with increased pain and edema in lower extremities, Doppler completed and noted without Deep vein thrombosis (DVT). Resident does continue to voice he/she would like to go home but does not feel he/she is ready. Nursing continues to work on pain management and Foley training has been complicated by poor dexterity. Labs today are significant for elevated white blood cell (WBC) and urine culture with bacteria. Call to physician (MD) to report labs a (sic) decline. Surveyor requested DON obtain a copy from Physician #1’s office of the urinalysis. Review of Nursing Notes, dated 6/29/25, did not indicate abnormal urinalysis lab results were communicated with physician and/or his designee. During an interview on 8/28/25 at 4:28 P.M., the DON said she called Physician #1’s office, and they do not have a copy of the lab results or fax which would have been sent back to the facility. The DON said she checked the electronic communication system used to communicate with physicians and said there was no notification to the physician or his designee with the results of the urinalysis on 6/29/25. Further review of the electronic medical record indicated there were no physician or Nurse Practitioner documentation of the abnormal urinalysis results reported to the facility on 6/29/25.

Based on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#13 and #86), out of a total sample of 27 residents. Specifically, the facility failed:1. For Resident #13, to ensure physician's orders were complete for the management of a continuous glucose monitoring sensor and included orders to remove and change the device every 14 days; and2. For Resident #86, to complete weekly skin check documentation per physician's orders.Findings include:1. Review of the facility's policy titled Freestyle Libre 2 Flash Glucose Monitoring System, June 2023, indicated but was not limited to: -Always obtain physician’s orders for the use of fingerstick blood glucose testing via a facility approved blood glucose meter to guide treatment decisions. -Review the resident’s orders to evaluate special needs of the resident. -Review and follow manufacturer's guidelines for use. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html) guidelines, included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingerstick; -The sensor lasts up to 14 days, and it is recommended to rotate application site of the sensor between arms. Resident #13 was admitted to the facility in July 2025 with diagnoses including diabetes mellitus, type 2. Review of the Minimum Data Set (MDS) assessment, dated 7/29/25, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out 15 and was receiving insulin. During an interview with observation on 8/25/25 at 10:42 A.M., the surveyor observed a glucometer (device used to measure blood glucose levels) on Resident #13’s nightstand. Resident #13 said the glucometer was used to check his/her blood sugar utilizing their Libre 2 monitor. He/she said their monitor was changed every 14 days and the nurses use it to check his/her blood sugar. Review of Resident #13's Physician's Orders indicated but was not limited to: -Insulin Lispro per sliding scale: if 1 - 149 = 0 units; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 6 units; 400 - 449 = 8 units; 450 - 499 = 10 units; 500 - 1000 = 12, subcutaneously before meals and at bedtime, 7/25/2025 Further review of Resident #13’s Physician's Orders failed to indicate orders for the use of the Libre continuous glucose monitoring device to implement the sliding scale, and orders to remove and reinsert the sensor device every 14 days. During an interview on 8/27/25 at 2:51 P.M., Nurse #1 said Resident #13 had a Libre Blood Glucose Monitor to monitor his/her blood glucose. She said she would check Resident #13's blood glucose either using his/her Libre monitor or via a fingerstick. Nurse #1 said when a resident had a Libre monitor they would need an order to change and apply a new monitor every 14 days, and an order for use of the device to obtain blood glucose levels to implement the insulin sliding scale. Nurse #1 reviewed Resident #13's medical record and said he/she did not have a physician's order to change the device every 14 days or to use the device to check his/her blood glucose. During an interview on 8/28/25 at 9:46 A.M., the Nurse Practitioner (NP) said Resident #13 had a Libre monitor and should have an order to change the monitor every 14 days and to use it to monitor their blood glucose. The NP reviewed Resident #13’s medical record and said he/she did not have an order to change the monitor or to utilize it to monitor their blood glucose levels but should have. During an interview on 8/28/25 at 12:56 P.M., the Director of Nursing (DON) reviewed Resident #13’s orders and said he/she did not have a physician's order to change the device every 14 days and to utilize the Libre to monitor their blood glucose levels but should have. 2. Resident #86 was admitted to the facility in April 2019 with diagnoses which included chronic peripheral venous insufficiency (a condition of impaired blood flow that can cause swelling, pain, and skin changes). Review of Physician’s Orders indicated, but was not limited to, the following: -Dermatological Consult related to bilateral lower extremity (BLE) skin inflammation (7/19/25); -Weekly skin check on Tuesday 7-3 shift (1/16/24). Review of the Resident's current care plan indicated, but was not limited to, the following: -I have impaired skin integrity related to bilateral lower extremity skin condition. I am at risk for skin impairment related to limited mobility, incontinence of bowel/bladder, diabetes. -Administer treatments as ordered and monitor effectiveness. Report abnormal findings to practitioner. Document findings and interventions. -Monitor for new or worsening signs and/or symptoms of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness, fever/chills, etc. Review of Resident #86’s medical record indicated his/her last weekly skin check was performed six weeks prior on 7/15/25 and indicated no skin issues. Review of the Resident's progress notes indicated an entry on 7/19/25 that stated the NP assessed the Resident for BLE skin buildup and discharge; new orders for labs and aerobic culture of the right lower extremity (RLE); NP prescribed Prednisone 40mg daily for 5 days, Clobetasol topically twice per day for 7 days, and a dermatology consult. During an interview on 8/28/25 at 2:05 P.M., the Director of Nursing (DON) reviewed the Resident’s medical record and said there was missing documentation of weekly skin checks. The DON said although the Resident’s legs were open to air and observed by staff during routine care, weekly skin checks should be documented in the electronic health record.

Based on observations, interviews and policy review, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling. Specifically, the facility failed to: 1. Ensure hair was restrained when preparing food; and 2. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 3. Ensure staff monitored cooked food temperatures being held for service to residents. Findings include: 1. Review of facility's policy titled Hair Restraints, dated 2020, indicated but was not limited to the following: -Hair Restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. During an initial tour of the main kitchen on 7/11/24 at 7:16 A.M., the surveyor observed: -Dietary staff #2 did not have hair restrained while preparing breakfast. -Dietary staff #4 did not have beard hair restrained while assembling breakfast trays. During an interview on 7/11/24 at 7:59 A.M., Dietary Staff #2 said she had forgot to restrain her hair prior to serving breakfast. During an interview on 7/11/24 at 8:34 A.M., the Food Service Director (FSD) said part of the dietary staff uniform is a hair net or hat to restrain hair. On 7/12/24 at 12:20 P.M., the surveyor observed Dietary staff #4 with no covering or restraint for his beard hair and his long hair was not fully retrained in a hair net as he prepared trays for resident's lunch. During an interview on 7/12/24 at 12:50 P.M., the FSD said Dietary Staff #4 did not have his hair fully secured in the hairnet and had no beard hair net covering his beard. During an interview on 7/15/24 at 1:04 P.M., the Administrator said all kitchen staff should wear hairnets or beard guards to prevent hair from encountering food. 2. Review of the Food and Drug Administration Food Code, dated 2022, indicated but was not limited to the following: -Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. - If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: -Inside the food establishment if the receptacles and units: Contain food residue and are not in continuous use; or after they are filled. During an initial tour of the main kitchen on 7/11/24 at 7:16 A.M., the surveyor observed: -Dietary Staff #2 failed to change gloves or perform hand hygiene in between touching pieces of French toast, syrup, hardboiled eggs, pancakes, and plates. She also failed to use serving utensils for French toast, hardboiled eggs, and pancakes. -Two large trash bins were uncovered, and one bin had trash overflowing on to the floor. During an interview on 7/15/24 at 1:04 P.M., the Administrator said the trash in the kitchen should be always covered. She said that the cooks should not be touching food even with gloved hands due to cross contamination. 3. Review of the Food and Drug Administration Food Code, dated 2022, indicated but was not limited to the following: -Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures Review of refrigerator temperature logs failed to indicate ongoing monitoring to ensure safe operation of refrigeration equipment to ensure cold foods were held at 41 degrees Fahrenheit (F) or below as follows: -Nourishment kitchen refrigerators were last taken on 7/1/24, 10 days prior. -Main kitchen refrigerators were blank on the dates of 6/12/24, 6/14/24 through 6/16/24, and 6/24/24 through 6/30/24. -Main kitchen refrigerators were not taken in July 2024. Review of the steam table temperature logs failed to indicate ongoing monitoring to ensure food items were being held above 135 degrees F as follows: -Steam table temperatures were blank on the date of 6/12/24, 6/14/24 through 6/16/24, and 6/24/24 through 6/30/24. -Steam table temperatures were not taken in July 2024. During an interview on 7/11/24 at 7:59 A.M., Dietary Staff #2 said she had not recorded the temperature of the food from the steam table prior to serving breakfast. During an interview on 7/11/24 at 8:34 A.M., the Food Service Director (FSD) said the steam table temperatures are required to be taken prior to the meal being served and recorded and it was concerning that there was a lack of temperatures recorded. She said the temperatures are recorded on the sheets on the clipboard and was unable to provide any additional information regarding the lack of logs. She said that it was her expectation that the temperatures for the refrigerators and freezers are recorded daily. She said she expects the cook to take and record the temperature of the food items on the steam table prior to serving the meal to ensure safe serving temperatures.

Based on observation, test tray results, and interview, the facility failed to ensure staff served food that is palatable and at an appetizing temperature for 2 out of 2 test trays conducted. Findings include: During initial resident screening on 7/11/24, the residents expressed the following concerns about the food served at the facility: -Food temperatures are cold for foods that are supposed to be hot. -The milk is warm. -The food served lacks palatability. -The bread is soggy. -There are missing items from tray and the meal tray is not reflective of meal ticket. On 7/15/24 at 10:30 A.M., the residents at the Resident Group Meeting expressed concern regarding the palatability of the food served at the facility. During an interview on 7/11/24 at 11:13 A.M., Resident #94 said the food is either tasteless or too salty. During an interview on 7/11/24 at 3:35 P.M., Resident Representative #1 said the food is awful, the meat is dry, and the vegetables have no flavor. Test Tray #1: On 7/12/24 at 12:00 P.M., the surveyor requested a lunch tray be sent to the Arborside Unit second meal truck which was to arrive to the unit at 12:15 P.M. The truck left the kitchen at 12:20 P.M and arrived at the unit at 12:21 P.M. The test tray was removed and conducted with the Food Service Director (FSD) obtaining temperatures in degrees Fahrenheit (F) with the facility thermometer at 12:37 P.M. with the following results: Baked fish-133.8 F, warm (not hot), flavorful Rice-118.5 F, tepid (lukewarm) and bland to taste. Spinach-118.7 F tepid and bland to taste. Coffee-151.7 F hot to taste. Milk-63.5 F warm to taste. Brownie (not temped) tasty with dry consistency. Test Tray #2: On 7/15/24 at 8:00 A.M., the surveyor requested a breakfast test tray to the Arborside Unit which was to arrive to the unit at 7:40 A.M. The food truck left the kitchen at 8:15, and arrived on the unit at 8:17 A.M the test tray and 2 other meals were not in the food truck but were brought to the unit in a cart that was not enclosed. The test tray was conducted with the FSD obtaining temperatures at 8:43 A.M., with the following results: Milk: 59.7 F, warm to taste. Black coffee: 139.2 F, warm to taste. Toast 97.8 F, cold, soggy, and bland to taste. Scrambled eggs 120.2 F mushy, little flavor, and tepid to taste. Results of the test trays validated the residents' concerns of cold food, warm milk, food lacking palatability. During an interview on 7/15/24 at 8:54 A.M., the FSD said she did not want to try the foods on the test tray. She said the food trucks were late today which can account for the hot foods not being hot and the cold foods being warm. She said that the Registered Dietitian had told her that meal trays are supposed to be inside of the meal cart to retain temperature. She said she was aware that there were a few trays that were not in a meal cart. During an interview on 7/15/24 at 10:38 A.M., the Registered Dietitian (RD) said the temperature for the milk was too high and the food was not within a range she would expect it to be served. She said she expects all food trays to arrive to the floor inside of a meal truck to preserve the temperature and she had communicated this concern with the FSD through the Test Tray Evaluation Forms. Review of Test Tray Evaluation Forms completed by the RD indicated the following: -On 5/20/24 the starch was a poor temperature at 109.9 F and the kitchen took longer to serve the food. -On 4/23/24 the temperatures were low at the start of tray pass and the vegetables temperature was 96.8 F pasta was 114 F. -On 4/16/24 the temperatures for pork and peas temperature were recorded as poor. -On 4/16/24 the temperatures for all hot items were marked as poor and comments include the tray was not in food truck and the temperature was not adequate. During an interview on 7/15/24 at 1:04 P.M., the Administrator said the trays should not be transported or left on top of the meal trucks and that she recently purchased another meal truck to ensure all meal trays would fit inside so foods would retain temperatures. She said she is aware of continued resident concerns related to food palatability as they are raised through the residents' Food Council Committee.

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure the treatment cart on Cookside Unit was locked when not in direct supervision of the licensed nurse; and 2. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 3 observed medication carts. Findings include: Review of the facility's policy titled Specific Medication Administration Procedures, dated as last revised December 2019, indicated but was not limited to the following: -Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct supervision of the medication nurse/aide. -Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container. Review of the facility's policy titled Medication Storage, dated as last revised October 2022, indicated but was not limited to the following: -The center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of health guidelines. -All medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. -Medication will be stored in an orderly, organized manner in a clean area. -Medication will be stored in the original, labeled containers received from the pharmacy. -Medication will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. -Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36-46 degrees Fahrenheit). 1. On 7/17/24 the surveyor made the following observations: -8:10 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. -8:59 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. A cell phone and binder were on top of it. -9:02 A.M., Staff member retrieved cell phone and binder from the top of the cart and left the unit. The cart remained unlocked in the hallway, not in view of staff. -9:22 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. -9:52 A.M., Surveyor brought Unit Manager (UM) #3 to the hallway where the treatment cart remained unlocked and not in view of staff. During an interview on 7/17/24 at 9:52 A.M., UM #3 said the treatment cart should be locked when not in use, and it should not be in the hallway unlocked. She said the cart should be stored in the clean utility room. During an interview on 7/17/24 at 11:28 A.M., the Assistant Director of Nurses (ADON) said the treatment cart should be kept in the clean utility room, unless in use, and it should be locked when not in use. She said the cart should not be in the hallway unlocked. 2. On 7/17/24 at 9:30 A.M., the surveyor inspected the Birchside Medication Cart with Nurse #9, and observed the following: -One of two insulin pens in the cart had no pharmacy (patient demographics) label attached, the pen had the number 218M written in black marker, and the words 0700 open. No other patient identifier was on the insulin pen. During an interview on 7/17/24 at 9:30 A.M., Nurse #9 said she knows that insulin pen belongs to the Resident in 218M, because they get it every day, but it should have the pharmacy label on it and the date opened/date expires label with dates written on it and the pen does not have either. She said the pen would need to be disposed of and re-ordered from the pharmacy. During an interview on 7/17/24 at 9:45 A.M., UM #2 said all insulins should have the pharmacy label and the opened/expires label on them and they should be dated when opened with the opened/expires date. She said that insulin pen needs to be thrown out and re-ordered. During an interview on 7/17/24 at 9:52 A.M., UM #3 said all insulin pens need to be labeled with the resident's name and the date opened/date expires written on the label. She said that pen needs to be replaced. On 7/17/24 at 11:18 A.M., the surveyor inspected the Arborside Medication Cart with Nurse #4, and observed the following: -Five insulin pens were stored in one Styrofoam cup together, not in individual plastic bags. One of the four pens had no cap on the pen leaving the rubber seal exposed. -Five boxes with insulin vials inside; 2 of the 5 vials were not labeled with date opened or date expires. -Two unopened insulins in their boxes and plastic bag from the pharmacy were in the med cart. Further review of the five insulin pens in the cup indicated the pens belonged to three different residents. -One had no pharmacy label, a resident's name was written in black marker, the open/expires dates were on the label. -Two had pharmacy labels with resident's names, but the open/expiries label had no dates written on it. -One had a pharmacy label with resident's name on it, however it was so faded, the name was almost completely removed from the white label, the open/expires dates were not written on it. Further review of the two opened insulin vials indicated they both had the pharmacy label on them, however neither had the opened/expires dates written on them. Further review of the two unopened insulin vials indicated they were both labeled from the pharmacy and inside the plastic bag from the pharmacy. One had a bright green label on the bag that said, Keep Refrigerated Until Opened and the other had a bright yellow label on the bag that said, Keep Refrigerated. Both insulin packages indicated the prescription was filled/dispensed from the pharmacy on 7/16/24. During an interview on 7/17/24 at 11:18 A.M., Nurse #4 said he does not know why the insulins were not labeled, stored in the cup, or not in the fridge. During an interview on 7/17/24 at 11:20 A.M., UM #1 said all insulins should be labeled with the pharmacy printed Resident label and the date opened/expires should be filled in when it is opened. During an interview on 7/17/24 at 11:28 A.M., the ADON said all insulins should be labeled with the printed pharmacy label and when the pen or vial is opened the date opened and date of expiration should be written on the label. She said the vials should be stored in their box and the pens should be in the individual plastic bags from the pharmacy. She said they should not be stored in a cup together.

Based on record review, interview, and policy review, the facility failed to follow professional standards of practice for two Residents (#343 and #104), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #343, to monitor the Resident's left upper extremity midline catheter insertion site for signs/symptoms of infection and/or infiltration every shift in accordance with the physician's order; and 2. For Resident #104, to ensure the physician conducted an accurate assessment of the Resident upon admission, per accepted standards of clinical practice, resulting in an inaccurate diagnosis of schizophrenia to be added to the Resident's list of active diagnoses. Findings include: 1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers 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. Review of the facility's policy titled Midline Dressing Change, date revised January 2023, indicated but was not limited to the following: -Assessment of peripheral catheter sites are performed at the following times: -A. During dressing changes -B. Every 2 hours during continuous therapy -C. Before and after administration of intermittent intravenous medications (or at least once every 8 hours between intermittent doses) -D. At least every 24 hours when maintained for access only -Assessment is to include the absence or presence of erythema (redness of the skin), drainage, swelling, induration (hardening or firmness); skin temperature at site, or complaint of tenderness at the site or along the vein tract Resident #343 was admitted to the facility in June 2024 with diagnoses including acute cholecystitis (gallbladder inflammation), liver disease, and abscess of the liver. Review of the Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident #343 had moderate cognitive impairment as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the Physician's Orders indicated but were not limited to the following: -IV-Midline (valved) monitor site every shift for signs/symptoms of infection and/or infiltration, dated 6/30/24, order type: monitoring order-MAR (Medication Administration Record), no routine schedule -IV-Midline (non-valved) monitor site every shift for signs/symptoms of infection and/or infiltration, dated 7/10/24, order type: NSG Order-MAR, schedule routine every shift, everyday Review of the MAR for July 2024 indicated there was no documentation from 7/1/24 through 7/9/24 that the IV-Midline (valved) site was being monitored every shift for sign/symptoms of infection and/or infiltration. Further review of the nursing progress notes indicated the following: -7/1/24 at 8:18 P.M., Continues IV antibiotics as ordered for cholecystitis via left arm midline without adverse effect. No complaints voiced. -7/6/24 at 11:19 P.M., Left arm midline clean, dry, flush with normal saline without resistance. No signs of infection noted. Review of the nursing progress notes, 7/1/24 through 7/9/24, failed to indicate Resident #343's midline had been monitored every shift. During an interview on 7/17/24 at 11:00 A.M., Nurse #5 reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. Nurse #5 said the order was not entered until 7/10/24. Nurse #5 said she did not know why there was no order for monitoring the insertion site until 7/10/24. During an interview on 7/17/24 at 11:24 A.M., Nurse #6 reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. Nurse #6 said she noticed there was no order attached to the MAR for the nurses to document. Nurse #6 said the original order was transposed as a standard order and did not populate to the MAR. Nurse #6 said she had correctly re-entered the order on 7/10/24. During an interview on 7/17/24 at 1:45 P.M., the Assistant Director of Nursing (ADON) reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. The ADON said the order had been entered incorrectly. The ADON said her expectation would be that nursing would have entered the order correctly and document on the MAR they were monitoring the midline insertion site for signs/symptoms of infection and/or infiltration every shift. 36542 2. Review of the facility's policy titled Antipsychotic Medication Use, dated last revised October 2022, indicated a diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. According to the American Psychiatric Association (APA) symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms may mimic schizophrenia. A diagnosis has clinical, personal and social significance. In the clinical context, a diagnosis reveals the nature of an illness. A correct diagnosis provides a basis for effective treatment. An incorrect diagnosis may delay or impede effective treatment or even exacerbate a situation by inviting inappropriate treatment. A diagnosis has personal significance insofar as it can become central to how a person experiences him- or herself. While a correct diagnosis of a severe disorder can be enormously difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling. A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placements. A diagnosis asserts itself on multiple levels of experience. Rendering a diagnosis can be a complex process. Consider, for example, that psychotic experiences are part of multiple diagnoses. The treatment for an affective disorder with psychotic features, a schizophrenic disorder, a post-traumatic stress reaction, a severe personality disorder and a substance abuse disorder can vary dramatically; yet, psychotic processes may be present in each. Making the correct diagnosis will depend on the psychologist engaging in a thoughtful and competent process and often requires having sufficient time and opportunity to interact with an individual in order to differentiate among various possibilities. ([NAME], S. APA Ethics Director (2005). Diagnosis, record reviews and the new Ethics Code. Monitor of Psychology, Volume 36 (No. 1), page 80. https://www.apa.org/monitor/jan05/ethics Resident #104 was admitted to the facility in March 2023 with a diagnosis of dementia with behavioral disturbance. Review of the psychiatric hospital discharge summary from March 2023 indicated Resident #104 had a diagnosis of dementia with behavioral disturbance. The discharge summary indicated this was the first inpatient psychiatric admission for Resident #104; the Resident had not had any symptoms of paranoia or hallucinations prior to January 2022 and there had been no history of mental health concerns. Review of the physician admission Progress Note, from the Nurse Practitioner, dated 3/27/23, indicated Resident #104 had a diagnosis of dementia with other behavioral disturbance, unspecified dementia severity, unspecified dementia type. The progress note listed six active diagnoses: dementia, hypertension, diabetes, seizure disorder, gastroesophageal reflux disorder, and low back pain. Review of the physician History and Physical Progress Note from the primary physician, dated 3/28/23, indicated Resident #104 had completed a psychiatric stay related to paranoid schizophrenia. The progress note listed seven active diagnoses including the six active diagnoses from the Nurse Practitioner and a new diagnosis of paranoid schizophrenia with a plan to continue the use of antipsychotic medication. Review of the medical record failed to indicate Resident #104 had a diagnosis of schizophrenia prior to the admission to the facility. Review of the Pre-Admission Resident Review Abbreviated Level II Evaluation, dated 3/8/23, indicated Resident #104 had a diagnosis of dementia and had presented with delusions and hallucinations. The evaluation did not indicate any history of schizophrenia. During an interview on 7/16/24 at 8:40 A.M., Physician #1 said he had completed the History and Physical for Resident #104. He said he would not have diagnosed the Resident with schizophrenia on his own and that he must have obtained the information from a record review of hospital discharge paperwork. He said he would review the information and follow up with the surveyor. During an interview on 7/16/24 at 10:00 A.M., the family member and guardian of Resident #104 said the Resident had no history of mental illness (including delusions or hallucinations) prior to 2022 and the Resident had a diagnosis of dementia. During an interview on 7/16/24 at 12:35 P.M., Physician #1 said he had only been able to locate information regarding a diagnosis of schizophrenia from after the March 2023 admission to the facility. He said he does not diagnose residents with schizophrenia and would only indicate the diagnosis if it had been given by a psychiatrist. The Physician requested to review the Resident history with the community providers. Review of the medical record included a hospital discharge summary from November 2023, following the diagnosis of schizophrenia from Physician #1 which indicated Resident #104 was admitted for a diagnosis of dementia with behavioral disturbance. The discharge summary indicated the history of present illness included a diagnosis of schizophrenia. Review of the electronic medical record indicated a diagnosis of schizophrenia was added to the active diagnoses as of 12/1/23. Review of the behavioral health group Progress Notes from August 2023 through December 2023 indicated Resident #104 had a chief complaint of dementia with behavioral disturbance with a primary diagnosis of psychotic disorder with delusions and a secondary diagnosis of unspecified dementia. Review of the behavioral health group Progress Notes from 4/10/24 and 5/29/24 indicated a chief complaint of paranoid schizophrenia with a primary diagnosis of paranoid schizophrenia. During an interview on 7/17/24 at 10:01 A.M., the Minimum Data Set (MDS) nurse said the diagnosis of schizophrenia was referenced in the medical record from Physician #1, the diagnosis was then sent with the Resident's medical information to the hospital in November 2023 and was added to the list of active diagnoses in the electronic medical record when the Resident returned from the hospital admission on 12/1/23. During an interview on 7/17/24 at 10:11 A.M., Physician #1 said he had reviewed the medical history of Resident #104 and the Resident did not have a diagnosis of schizophrenia. He said the diagnosis of schizophrenia should not have been included on the list of diagnosis on his Progress Notes. He said the correct diagnosis for the Resident was dementia with paranoia.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from Resident Council were acted upon and promptly resolved from 12/6/23 through 7/8/24 as required. Findings include: Review of the facility's policy titled Resident Council, dated as last revised 1/2023, indicated but was not limited to the following: -Concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. All supporting documentation (i.e., in-services, staff education, clinical notes) must be attached. Concern/response forms must be completed within 7 days of being issued. Review of the facility's policy titled Grievances, dated as last revised 10/2023, indicated but was not limited to the following: -The Grievance Officer coordinates adequate and timely handling of grievances/complaints and ensures the grievances/complaints and resolutions are maintained and reviewed with administration routinely. Review of the Grievance/Concern & Comment Form, dated 1/9/24, indicated Resident Council had voiced concerns which included requesting more soups to be offered, late dinner trucks, missing items on trays, and the menu not being followed. -The facility indicated tray time audits would be done and food concerns were being addressed during the newly established Food Committee (Established in December 2023 due to repeated food concerns in the fall). Review of the Food Committee Meeting Minutes, dated 12/6/23, indicated the resident's voiced concerns regarding daily soup no longer being offered, missing items on trays, individual likes/dislikes were not correct, too much pork especially at breakfast, and not getting snacks offered twice daily. Review of the Food Committee Meeting minutes, dated 1/16/24, indicated the same food concerns voiced from the 12/6/23 Food Committee Meeting and the 1/9/24 Resident Council Meeting. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Food Committee Meeting minutes, dated 2/22/24, indicated the same food concerns voiced from the 12/6/23 Food Committee Meeting, the 1/9/24 Resident Council Meeting, and the 1/16/24 Food Committee Meeting. -The facility indicated the Food Service Director and Dietitian were reviewing the menu and would address the pork and starch concerns with dietitian approved changes. Additionally, they were working on starting soup of the day in the main dining room (MDR) and the frequency was to be determined. The facility indicated a plan had been developed to address resident concerns regarding the pork, starches, and soups (three months after the Food Committee was developed due to ongoing food complaints), however, as of July 2024, failed to implement such plan. Review of the Grievance/Concern & Comment Form, dated 2/29/24, indicated repeated food concerns without resolution and additional concerns with call light wait times. Review of the Grievance/Concern & Comment Form, dated 5/7/24, indicated Resident Council had continued concerns regarding evening snacks not always being passed, trays being delivered late, the menu was not always followed, and long call light wait times. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Resident Council Meeting minutes, dated June 2024, indicated the facility was working on the menu to incorporate local food preferences such as soup. Additionally, the Council indicated they were not in agreement with the Dietary Department that food trucks were no longer late as meals were consistently late, and call light wait times were an ongoing issue. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Grievance/Concern & Comment Form, dated 6/11/24, indicated Resident Council concerns included call lights continue to be extremely long, over an hour some days, and the evening snack pass was not being done. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Resident Council Meeting minutes, dated 7/9/24, indicated the facility was working on the menu to incorporate local food preferences such as soup. (Repeated from last month.) Additionally, the Resident Council continued to express concerns regarding long call light wait times and late meal delivery, food preferences not being followed, and snacks not being passed. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. On 7/12/24 at 10:30 A.M., the surveyor held a Resident Council Meeting with 18 residents that regularly attend meetings. The following concerns were voiced by the Council as repeated concerns that they felt had not resolved: daily soup not being offered, not getting the correct items on trays, evening snack not being passed out, meal delivery very late, and call light wait times were excessively long. Additionally, they said they requested to be part of the call light audits that are supposedly being done and have never seen them or been part of them. Several residents said call lights wait times are 30-45 minutes regularly, sometimes over an hour. Four residents said when no one answers the call light they have called the facility from their personal cell phone to get assistance. The Council said the results of the grievances are so-so, and minor individual things get resolved, but overall, they do not feel the issues/concerns they have repeatedly brought up have been addressed and a resolution has not been brought back to the council. The facility developed a Food Committee to address ongoing resident complaints. The Food Committee failed to address repeated resident concerns. After three months (late February 2024), the facility developed a plan to incorporate more soup on the menu, specifically in the MDR. In July 2024, this plan had yet to be implemented and the residents continued to voice the same repeated concerns. The facility failed to provide documentation related to the resolution of the grievances Resident Council had repeatedly brought forward. During an interview on 7/12/24 at 2:00 P.M., the Administrator said the Food Committee was developed in December 2023 because of repeated food complaints. She said the Committee was to meet monthly to discuss food complaints in addition to the monthly Resident Council Meetings. She said the complaints were the same as what was being brought forth in Resident Council. The Administrator said they did not meet monthly as planned and did not think the meetings had been very effective to address the Residents' food concerns. During an interview on 7/17/24 at 1:40 P.M., the Administrator said the Food Committee consists of herself and the Food Service Manager (FSM). She said some of the smaller concerns have been resolved but the larger issues have not. She said regarding the late meal trucks, they did audits and concluded it was the passing out of the trays that was the issue, but it still has not been resolved. Additionally, she said the facility used to have a daily soup and when they switched providers in October 2023 that went away. She said the residents have been asking for more soup since at least December (7-8 months). The addition of soup was supposed to start in the MDR, but it has not, as the dietitian has not reviewed the menu and approved the changes, and the grievance remains unresolved. Despite tray accuracy audits by the dietitian, the residents continue to complain that they are getting the wrong items on their trays. Despite using a cart with a bell to alert the residents of evening snack time, the residents are still complaining that an evening snack is not being offered, and the concern has not been resolved. Regarding the call lights, the Administrator said the Director of Nurses was doing the call light audits, but she was not available to speak with at the time of the survey and the audits were not provided. The Administrator said the residents continue to request to be part of the audit process as they continue to have concerns with call light wait times. The Administrator said the system needs improvement as these grievances are being repeated monthly and change has not been implemented or is ineffective therefore, they are not being resolved as they should be. During an interview on 7/17/24 at 2:28 P.M., the FSM said they started the Food Committee in December 2023, but it is not effective. She said regarding the daily soups, she said she had to meet with the Dietitian to make changes to the menu and add soup, but she had not done that yet. Regarding the tray accuracy audits, she said the issues continue because the meal tickets no longer print what should be put on the tray; the ticket only lists the residents' dislikes, and the staff (the cook and two dietary aides) must make substitutions while preparing the trays, leaving room for error. The FSM said they were working on the areas of concern: not having soup available, late meals, and getting items they do not like, but there has not really been a resolution to their complaints.

Based on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed. Findings include: Review of the breakfast menu for 7/11/24 indicated that residents should have received French toast casserole, sausage, choice of hot or cold cereal. On 7/11/24 at 7:30 A.M., the surveyor observed Dietary Staff #2 preparing breakfast trays with French toast instead of a French toast casserole. During an interview on 7/11/24 at 7 A.M., Dietary Staff #2 said this is what is for breakfast and was unaware of a French toast casserole being on the menu. During an interview on 7/11/24 at 11:13 A.M., Resident #94 said they are unaware if the food served differs from the menu until a meal is served. He/She said the kitchen beats to its own drum, and he/she can't depend on the menu for accuracy. He/She said they had cookies for dinner last night because he/she didn't like the meal and a request for a tuna sandwich took over an hour. Review of the lunch menu for 7/15/24 indicated that residents should have received beef and broccoli stir fry, steamed rice, vegetable blend, blushing pears, and an egg roll. On 7/15/24 at 12:20 P.M., the surveyor observed lunch trays being passed on the Birchside Unit with no egg rolls present. Review of the breakfast menu for 7/17/24 indicated that residents should have received sausage, egg of choice, and cinnamon toast. On 7/17/24 at 8:04 A.M., the surveyor observed the cook preparing breakfast trays with plain toast and scrambled eggs. The breakfast sausage was not available. During an interview on 7/17/24 at 08:34 A.M., Dietary staff # 3 said that the breakfast was scrambled eggs and toast, she said they did not have cinnamon and they had sausage yesterday. She said she was unsure why it was on the menu today but it was not available. During an interview on 7/17/24 at 12:14 P.M., the Food Service Director (FSD) said that sometimes items are not available to order from the vendor. She said she was unable to order eggrolls, cinnamon toast, and the sausage for today. She said that she does not communicate with the residents if an item is not available. She said she lets the activities staff know if there are omissions or substitutions. During an interview on 7/17/24 at 12:35 P.M., Activities Assistant #1 said the kitchen does not inform activities if they do not have an item to serve. She said there is no communication regarding menu changes. During an interview on 7/17/24 at 12:23 P.M., the Registered Dietitian said she was unaware of any menu changes and the FSD should inform her if there are any changes in the menu. She said the kitchen also needs to communicate with the residents if something is served other than what is on the menu. During an interview on 7/17/24 at 12:40 P.M., the Administrator said the kitchen should communicate any menu changes with the residents and the dietitian to ensure the meal still meets the nutritional needs of the residents. During an interview on 7/17/24 at 12:46 P.M., the Activity Director said the kitchen doesn't tell us if a menu item is unavailable or if there are changes to the menu we post. She said that she knows this frustrates the residents and it is often brought up at the monthly Resident Council Meeting.

Based on record review and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards for two Residents (#99 and #115), in a sample of 26 residents. Specifically, the facility failed to ensure the electronic medical record orders accurately reflected the advanced directives indicated on the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #99 and Resident #115. Findings include: 1. Resident #99 was admitted to the facility in September 2022. Review of the medical record indicated the designated Health Care Proxy for Resident #99 signed a new MOLST changing the code status from a Full Code (attempt resuscitation) to a Do Not Resuscitate, Do Not Intubate on 10/29/23. Review of the electronic medical record on 7/12/24, including physician orders and a section designated Code Status indicated Resident #99 was a full code (resuscitation would be attempted). The electronic medical record did not reflect the accurate code status of Do Not Resuscitate from the MOLST signed on 10/29/23. During an interview on 7/16/24 at 11:02 A.M., Unit Manager #1 said the electronic medical record code status section and orders should reflect the changes made to the MOLST in October 2023 and the medical record was not accurate. 2. Resident #115 was admitted to the facility in August 2023. Review of the medical record indicated on 3/13/24 Resident #115 signed a new MOLST indicating the Resident would continue with a code status of Do Not Resuscitate and added the directive of no longer wanting to be sent to the hospital, did not want to have artificial nutrition, and did not want to have artificial hydration. Review of the electronic medical record on 7/12/24, including physician orders and a section designated Code Status indicated Resident #115 had orders to be transferred to the hospital, was undecided on artificial nutrition and was undecided on artificial hydration. The electronic medical record did not reflect the accurate directives of do not hospitalize, no artificial nutrition and no artificial hydration from the MOLST signed on 3/13/24. During an interview on 7/16/24 at 11:02 A.M., Unit Manager #1 said the electronic medical record code status section and orders should reflect the changes made to the MOLST in March 2024 and the medical record was not accurate.

Based on record review and interview, the facility failed to ensure one Resident (#40), out of a total sample of 26 residents, was free from unnecessary psychotropic medication. Specifically, for Resident #40, the facility failed to ensure an antipsychotic was given to treat a specific condition. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised October 2022, included but was not limited to: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. -Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting Diagnosis -Gradual dose reductions attempted Resident #40 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #40 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #40 had received an antipsychotic medication. Review of the medical record indicated a Physician's Order for Quetiapine Fumarate (an antipsychotic, used to treat symptoms of psychosis such as delusions, hallucinations, paranoia, or confused thoughts) oral tablet 25 milligrams (mg) one tablet at bedtime for behaviors (6/25/24). Further review of the medical record indicated a pharmacy consultant recommendation, dated 6/26/24, indicated: -This patient is currently receiving an antipsychotic medication and documentation of a diagnosed specific condition is unclear. Please provide an appropriate specific indication for use. Diagnosis of dementia without behaviors is listed. -If the medication is no longer indicated, please consider a dose reduction of 25-50% with the goal of discontinuation. The Physician placed a checkmark next to disagree and signed on the signature line. There was no rationale for disagreeing with the consultant pharmacist's recommendation documented on the form or in the medical record. Review of the Nurse Practitioner's (NP) progress notes indicated the following: -6/26/24: advancing dementia, stable mood, otherwise no behavior problem continue to monitor -7/1/24: psych: stable, alert, oriented, cooperative, Alzheimer's disease with late onset, continue with supportive measures, monitor mood and behavior, follow up in house psych as needed, continue with Seroquel -7/15/24: psych: stable, alert, oriented, cooperative, Alzheimer's disease with late onset, continue with supportive measures, monitor mood and behavior, follow up in house psych as needed, continue with Seroquel Review of the medical record failed to indicate the medical rational for the use of an antipsychotic medication. During an interview on 7/17/24 at 11:02 A.M., Nurse #6 reviewed the medical record and said Resident #40 was not being seen by psychiatric services as he/she had no behaviors. Nurse #6 said the Physician did not provide an appropriate diagnosis for the usage of the antipsychotic medication. During an interview on 7/17/24 at 1:20 P.M., the Assistant Director of Nursing (ADON) said Resident #40 currently had no behaviors and was receiving an antipsychotic medication prior to admission to the facility. The ADON said the physician would not have a Resident seen by psychiatric services when they are not displaying signs of behaviors. The ADON said the physician would not adjust or discontinue any antipsychotic medications if a Resident was admitted to Short Term Rehab (STR). The ADON said Resident #40 had been admitted to STR and would be going back to his/her prior living situation. The ADON said Resident #40's diagnoses did not support the use of Quetiapine Fumarate. The ADON said the Physician should have provided an appropriate diagnosis for the usage of the antipsychotic medication.

Based on record review and interviews, the facility failed to ensure the Physician documented a clinical rationale for disagreeing with the consultant pharmacist's identified and reported irregularity (order for an antipsychotic medication without supporting diagnosis for usage) for one Resident (#40), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting Diagnosis -Gradual dose reductions attempted Resident #40 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #40 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #40 had received an antipsychotic medication. Review of the medical record indicated a Physician's Order for Quetiapine Fumarate (antipsychotic) oral tablet 25 milligrams (mg) one tablet at bedtime for behaviors (6/25/24). Further review of the medical record indicated a pharmacy consultant recommendation, dated 6/26/24, indicated: -This patient is currently receiving an antipsychotic medication and documentation of a diagnosed specific condition is unclear. Please provide an appropriate specific indication for use. Diagnosis of dementia without behaviors is listed. -If the medication is no longer indicated, please consider a dose reduction of 25-50% with the goal of discontinuation. The Physician placed a checkmark next to disagree and signed on the signature line. There was no rationale for disagreeing with the consultant pharmacist's recommendation documented on the form or in the medical record. During an interview on 7/17/24 at 11:02 A.M., Nurse #6 said the Physician should have documented a rationale for disagreeing with the consultant pharmacist's recommendation to provide an appropriate diagnosis for the usage of the antipsychotic medication. During an interview on 7/17/24 at 1:20 P.M., the Assistant Director of Nursing (ADON) said Resident #40 currently had no behaviors and was receiving the antipsychotic medication prior to admission to the facility. The ADON said Resident #40's diagnoses did not support the use of Quetiapine Fumarate. The ADON said the Physician should have written a rationale for disagreeing with the pharmacist's recommendation and provided an appropriate diagnosis for the usage of the antipsychotic medication.

Based on observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#115), out of 26 sampled residents, to address the Resident's hearing loss. Findings include: Resident #115 was admitted to the facility in August 2023. Review of the Minimum Data Set (MDS) assessment, dated 5/23/24, indicated Resident #115 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 7/11/24 at 8:20 A.M., Resident #115 said he/she was unable to hear the surveyor and asked the surveyor to speak louder. The Resident said he/she did not have hearing aids but hoped to be getting them soon. On 7/17/24 at 7:47 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 assisting Resident #115 to get set up for breakfast. The surveyor observed Resident #115 tell CNA #2 that he/she could not hear the CNA. Review of the Social Work progress notes, dated 3/13/24, indicated Resident #115 requested an appointment for a hearing evaluation and reported more difficulty hearing. The progress note indicated the unit secretary was made aware. Review of the medical record failed to indicate Resident #115 had been seen by an audiologist for difficulty with hearing in the four months since the request was made. During an interview on 7/17/24 at 7:53 A.M., Unit Manager #1 said Resident #115 had some difficulty hearing and could hear when spoken to with a raised voice. She said the Resident had been seen by the primary care physician and was treated for wax removal from the ears in January 2024. She said she was not sure if the Resident had been referred to an audiologist and would follow up. During an interview on 7/17/24 at 8:50 A.M., Unit Manager #1 said the Resident had not seen an audiologist and no follow up had been made to the Resident's request for a hearing evaluation four months prior.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#115), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #115. Findings include: Review of the facility's policy titled ADL - Nail Care, undated, indicated the following: -the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections -nail care includes daily cleaning and regular trimming -trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin Resident #115 was admitted to the facility in August 2023. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/23/24, indicated the Resident was dependent on one staff person for personal hygiene and that Resident #115 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of the Care Plans indicated Resident #115 was at risk for skin impairments related to frail skin with an intervention to avoid scratching. On 7/11/24 at 8:20 A.M., the surveyor observed Resident #115 to have long fingernails varying in length which had a brown tint. During an interview on 7/12/24 at 12:40 P.M., the surveyor observed Resident #115 using a small wooden tool to pick underneath his/her nails and the Resident said he/she did not like their nails this long. Resident #115 said he/she had asked for a manicure but no one would do it. The Resident said he/she had been trying to fix their own nails by breaking them. The Resident pointed to their middle finger and said he/she did not know what happened to that one, the middle fingernail was observed jagged with broken parts over the nail bed. The Resident said the longer nails were hard. During an interview on 7/12/24 at 12:50 P.M., Certified Nursing Assistant #1 said she was caring for Resident #115 on this day, was working until 7:00 P.M. and would cut the Resident's nails. She said the CNAs can cut resident's nails and they were usually done during shower days. During an interview on 7/16/24 at 8:15 A.M., Resident #115 said no one had cut their nails this weekend and he/she had broken another one. The surveyor observed the Resident to have a long thumb nail on the left hand and long thumb, middle and pinky nail on the right hand. The Resident said he/she just wants someone to cut them, nothing fancy. During an interview on 7/16/24 at 8:20 A.M., Unit Manager #1 said the Resident's nails should have been cut during shower day, even if the Resident does not get out of bed to get showered, the nails should still be cut on that day. She said the Resident's nails should have been trimmed.

Based on observation, record review, and interview, the facility failed to ensure that for one Resident (#43), out of a total sample of 26 residents, the nurse provided the Resident privacy while administering medication, specifically an insulin injection. Findings include: Review of the facility's policy titled Specific Medication Administration Procedures, undated, included but was not limited to the following: Policy To administer medications in a safe and effective manner. B. Privacy: 1) Provide privacy for resident during administration of medications. Review of Resident #43's current Physician's Orders indicated: -Tresiba (antihypoglycemic medication; insulin), 100 units/milliliter, inject 15 units subcutaneously once daily. On 7/16/24 at 4:10 P.M., the surveyor observed Nurse #8 at the medication cart in the hallway drawing up the ordered dose of Tresiba in an insulin syringe. The surveyor heard Nurse #8 call Resident #43, who was standing in the hallway waiting for the medication to be administered, and then ask the Resident where he/she wanted the medication injected. With multiple residents and staff in the area, the surveyor observed Resident #43 lift his/her shirt, exposing his/her abdomen, and Nurse #8 administered the medication in the Resident's left lower abdomen. During an interview on 7/16/24 at 4:15 P.M., Nurse #8 said she didn't understand that she had not respected the Resident's privacy by administering the Resident's insulin in the middle of the corridor where other residents and staff were present. During an interview on 7/17/24 at 1:04 P.M., Unit Manager (UM) #1 said that Nurse #8 had discussed the situation with her and said that she made a mistake by administering the insulin in the hallway. UM #1 also said that insulin should always be administered to a resident in the resident's room to afford them privacy and that the nurse should have known that.

Based on observation, record review, and interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, for two Residents (#7 and #49), the facility failed to ensure the Residents' food preferences were met. Findings include: Review of the facility's policy titled Food Preferences, dated 2020, indicated but was not limited to the following: -Resident food preferences are kept on file in the Dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/27/24, indicated that Resident #7 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). During an interview with an observation on 7/15/24 at 12:45 P.M., Resident #7 said the food that arrives on meal trays does not match the meal tickets which indicates resident preferences. The Resident said that his/her meal ticket indicates that he/she dislikes rice but he/she continues to receive rice when it is served. The Resident said the meal ticket indicated he/she is supposed to get chocolate milk and ice cream, but he/she rarely receives it. The Resident said that he/she often asks for these items after the tray is delivered. The surveyor observed the resident's meal tray which listed rice as a dislike while being served rice and failed to include the items on the meal ticket. During an interview on 7/15/24 at 12:45 P.M., the Food Service Director (FSD) said if someone has a noted food preference it is on the meal ticket and the kitchen would honor the preferences (likes and dislikes). She said instead of rice, a resident who disliked rice should have received mashed potatoes instead. She was unsure why Resident #7 did not receive mashed potatoes. She said the cook is supposed to read the meal tickets and identify preferences and allergies prior to plating a meal. During an interview on 7/15/24 at 12:16 P.M., Resident Representative #1 said Resident #49 was supposed to get a hot dog or grilled cheese every day just in case the Resident doesn't like the meal. Resident Representative #1 said often these items do not come on the tray, and she needs to request that the always available items are sent to the Resident. Review of Resident #49's meal ticket indicated it did include the preference for a grilled cheese or hot dog to be sent on the tray daily for lunch and supper. Review of the Resident's lunch tray indicated the facility failed to follow the meal ticket and provide a hot dog or grilled cheese. During an interview on 7/17/24 at 1:40 P.M., the Administrator said the meal tickets are printed in the kitchen and have likes/dislikes/preferences on the top, and if the main meal has an item on the dislikes list, then the kitchen must make a swap while preparing the trays. For example, if someone dislikes rice and lunch is stir fry, the cook will need to read the ticket, identify the dislike, and make the swap to mashed potatoes. She said it is not a very effective system as they must read the dislikes on every ticket multiple times while preparing the trays.

Based records reviewed and interviews, for one of four sampled staff members personnel files (Nurse #1), the Facility failed to ensure they consistently implemented measures related to abuse prevention and hiring practices, when training on the Facility Abuse Policy was not conducted on hire at orientation for Nurse #1, in accordance with the Facility Policy. Findings include: Review of the Facility Policy titled Abuse, dated as most recently revised 10/23/22, indicated that Facility personnel will be trained on hire at orientation on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse. Review of Nurse #1's Personnel File, maintained by a staffing agency and provided to the Surveyor by the Facility Director of Nursing, indicated there was no documentation to support that the Facility or the staffing agency trained Nurse #1 on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. During an interview on 9/11/23 at 1:00 P.M., the Director of Nursing said that there was no documentation to support that the Facility or the staffing agency trained Nurse #1 on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. During an interview on 9/22/23 at 9:40 A.M., the [NAME] President of the Staffing Agency (that employed Nurse #1) said she did not have documentation of the agency having trained Nurse #1 on the Facility's Abuse Policy or on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. Although the [NAME] President provided copies of training materials from the staffing agency orientation, which included information on abuse, there was no documentation in the materials provided that supported that Nurse #1 had attended an orientation or received the training materials. The [NAME] President said that she thought that each individual facility where an agency nurse was assigned and worked, reviewed orientation documents with the nurse, including their Abuse Policy, when the agency nurse reported to work at their Facility.

Based on records reviewed and interviews, for one of three sampled personnel records (Nurse #1) and for the last four nurses hired by the Facility (Nurses #2, #3, #4 and #5) the Facility failed to ensure they consistently implemented measures related to abuse prevention measures through hiring practices, when Massachusetts Nurse Aide Registry (NAR) checks were not conducted upon hire, in accordance with the Facility Policy. Findings include: Review of the Facility's Abuse Policy, dated as revised 10/23/22, indicated that the Facility abuse prevention protocol included screening potential employees. The Policy indicated that the Facility screening process consisted of inquiries into State NARs. Review of Nurse #1's Personnel File, who started working at the Facility on 8/31/22, indicated there was no documentation to support the Facility conducted a Massachusetts Nurse Aide Registry check, upon hire. During an interview on 7/05/23 at 12:15 P.M., the Business Office Manager said that her job included conducting screenings of potential employees, which included conducting inquiries into the Massachusetts NAR. The Business Office Manager said that she only inquired into the status of Certified Nurse Aides (CNAs) on Massachusetts NAR and said that she could not provide documentation that the Facility checked Nurse #1's status on the Massachusetts NAR at the time of her hire. Review of the Facility's New Hires Report, dated 7/05/23, indicated the Facility hired four nurses (Nurses #2, #3, #4 and #5) since April 2023. The Business Office Manager said that she had not inquired into the statuses of Nurses #2, #3, #4 and #5 on the Massachusetts NAR. During an interview on 7/05/23 at 12:20 P.M., the Director of Nursing said that since April 2023 she had been aware that the Facility was not conducting inquiries into the Massachusetts NAR for newly hired nurses.

NOT CORRECTED Based on observations, interviews, and record review, the facility failed to ensure one Resident (#91), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of a pressure injury. Specifically, the facility failed to implement treatments as ordered, notify the physician, and reassess worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to an unstageable pressure area to the Resident's coccyx. Findings include: Review of the facility's policies titled Wound Ulcer, initiated 1/2023, and Wound Treatment Guidelines, last revised 1/2023, indicated the following: -A skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open. -The licensed nurse shall: -Document wounds/skin impairments in the electronic medical record including wound measurements, will reflect if dressing is intact, drainage noted, pain associated with the wound, any odor and condition of surrounding skin which is visual around dressing -Notification of medical provider of new or worsening wound -Refer the wound to wound care specialist or facility medical provider for further evaluation and treatment recommendations Resident #91 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease and acute kidney failure. Review of the 3/16/23 Minimum Data Set (MDS) assessment indicated Resident #91 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15, was frequently incontinent of bowel, was at risk of developing pressure ulcers, and had no unhealed pressure injuries, or other wounds or skin problems. Review of the April 2023 Physician's Orders indicated: -Apply Dermaseptin (barrier cream) to buttocks every shift (10/14/22) -Apply Dermaseptin to buttocks as needed (11/25/22) -May be evaluated and treated by wound Physician (9/14/22) Review of Resident #91's quarterly Norton Scale (a pressure injury risk assessment scale), dated 3/31/23, indicated he/she was at high risk for pressure injury, due to being chairbound, limited mobility, and double incontinence and in fair physical condition. During an interview on 5/9/23 at 12:35 P.M., Unit Manager #1 said while she was on-call over the weekend from 4/21/23 to 4/23/23 (she could not recall which day), she received a call from a nurse caring for Resident #91 to notify her of a new area on the Resident's buttocks. Unit Manager #1 said she told the nurse she would look at it when she came into the facility on Monday. Unit Manager #1 said that the Assistant Director of Nursing must have received a message as well because she saw the Resident on 4/24/23. Review of nursing notes from 4/21/23 to 4/23/23 failed to indicate documentation that a new area had been identified on Resident #91's buttocks and new treatment orders obtained. However, review of the April Treatment Administration Record (TAR) indicated a new treatment for the Resident's upper buttocks of wash with normal saline, pat dry, apply house moisture barrier cream, cover with dry protective dressing, once a day on the 7:00 A.M. to 3:00 P.M. shift was ordered on 4/21/23. The TAR indicated the following descriptions of the area to the Resident's upper buttocks: -4/21/23, pink, intact -4/22/23, pink, fragile -4/23/23, fragile -4/24/23, open, red. Comment: open area 2 centimeters (cm) x 3/4 cm (no depth documented) Review of a 4/25/23 Wound Management Report and a 4/25/23 late-entry nursing note (for 4/24/23) written by the Assistant Director of Nursing (ADON) indicated a new MASD wound was observed to the Resident's right buttock at 5:47 A.M. The wound bed was diffused with irregular edges, pink/no drainage, no odor, and measured 0.75 cm x 2 cm x less than 0.1 cm. The surrounding area was described as clean/dry/intact. The Resident is incontinent of bowel and reported that he/she does not know when he/she is moving his/her bowels. Nursing consulted with the house physician and requested treatment orders. The physician added skin prep around wound to the current treatment order on 4/24/23. The medical record failed to indicate the physician was notified, the Resident was reassessed or referred to the wound Physician when the wound changed from pink and fragile to red and open and the ADON documented her findings on 4/25/23 at 5:47 A.M. During an interview on 5/8/23 at 12:35 P.M., Nurse #1 said when she saw that Resident #91's wound had changed from pink to a beefy red on 4/24/23, she should have written a nursing note and notified the physician. She said she just told the oncoming nurse at the change of shift that day. Further review of the April 2023 TAR indicated: -4/25/23, open, pink -4/26/23, open, pink -4/27/23, treatment not administered, noted that Resident was unavailable -4/28/23, no description of the wound The Resident was not provided wound treatment as ordered on 4/27/23. Review of a 4/28/23 Wound Management Report indicated the Resident's wound appeared to be stable and measured 0.8 cm x 1.7 cm x 0.1 cm with partial thickness, pink wound bed, granulation (the development of new tissue and blood vessels in a wound during the healing process) 100%, no drainage, no odor, irregular edges, diffused. Resident denies pain. Further review of the April 2023 TAR indicated: -4/29/23, right upper buttock stage 1, open, red, no drainage -4/30/23, red, open, no drainage -5/1/23, red, open -5/2/23, red -5/3/23, stage 1, open, red, moderate drainage -5/4/23, treatment not administered The Resident was not provided wound treatment as ordered on 5/4/23. The medical record failed to indicate the physician was notified of the change, the Resident was reassessed for new treatment interventions or referred to the wound physician due to a change in condition of the wound (identified by nursing as a stage 1 wound), remained red, open and developed moderate drainage. Review of a 5/5/23 Wound Management Report written by the ADON indicated the Resident's wound was declining and measured 6 cm x 5 cm x 0.1 cm. The Resident was seen by the consultant wound physician on 5/5/23, 11 days after nursing staff documented a change in condition of the MASD wound that worsened from pink and intact, to red and open. Review of a 5/5/23 Initial Wound Evaluation and Summary from the consultant wound physician indicated Resident #91 has an unstageable pressure wound to his/her coccyx of at least 7 days duration, with moderate serous exudate (a clear, thin, watery fluid). The wound measured 6 cm x 5 cm x 0.1 cm with a surface area of 30 square cm. Treatment recommendations were to treat the wound with Alginate calcium with silver, apply twice daily for 30 days, Superabsorbent gelling fiber with silicone border and apply twice daily for 30 days, Skin prep apply twice daily for 30 days, Vitamin C 500 milligrams (mg) twice daily, and a low air loss mattress. An order for a low air loss mattress set to 200 pounds (lbs.) was initiated on 5/5/23. Review of H & R Healthcare manufacturer's user manual for an IPS Technology low air loss mattress indicated the mattress is to be set according to a patient's weight. Review of Resident #91's weight record indicated the Resident weighed 155.4 lbs. on 4/4/23. The surveyor observed Resident #91 lying in bed supine on an air mattress that was on and set to 200 lbs. on the following occasions: -5/8/23 at 11:50 A.M. -5/9/23 at 9:22 A.M. -5/9/23 at 11:09 A.M. -5/9/23 at 12:10 P.M. -5/9/23 at 4:06 P.M. During an interview on 5/9/23 at 9:35 A.M., the ADON said nursing staff identified the area on Resident #91's buttocks sometime over the weekend of 4/21/23 through 4/23/23 and she found out about the wound on 4/24/23. The ADON said she assessed the Resident on 4/24/23 and the wound was not open at that time. She said she was not notified by nursing later in the day that the wound had opened. The ADON said she next assessed the wound and took measurements on 4/28/23 but did not make a referral to the wound physician. She said the wound physician evaluated the Resident on 5/5/23, and the wound had deteriorated from a MASD to an unstageable pressure ulcer and made treatment recommendations including a low air loss mattress set to the Resident's weight. She said nursing staff are supposed to document daily in the medical record regarding a description of the wound and inform the physician of any changes, but they did not. She said the MASD wound would not have worsened to a pressure ulcer if there was daily documentation to reflect the changes in the wound, the physician was informed of the changes and interventions were implemented timely. During an interview on 5/9/23 at 10:17 A.M., Physician #1 said that he did not know about Resident #91's wound prior to 5/5/23. He said he learned of it when he saw the wound consultant's notes and recommendations. He said he did not know which physician was contacted on 4/21/23 and gave orders for treatment of the MASD. He said he would have ordered interventions earlier in an effort to prevent it from worsening to an unstageable pressure wound if he had known about it.

Based on policy review, record review, and interviews, the facility failed to maintain an environment free of accident hazards for one Resident (#53), out of a sample of 21 residents. Specifically, the facility failed to ensure an adverse medication event, which necessitated the Resident to be emergently transferred to the hospital for evaluation and resulted in psychosocial distress to the Resident, was investigated and reported according to facility policy. Findings include: Review of the facility's policy titled Accidents and Incidents, last revised [DATE], included but was not limited to: -It is the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. Procedure: The following forms make up the Incident and Accident Packet for investigating and reporting: -Accident and Incident Report Form -Incident/Accident Statement Form Registered Nurse (RN) Supervisor/Unit Manager -Incident/Accident Statement Form Involved Party Statement-for all those involved -CNA (certified nursing assistant) Statement Form-for those on duty at the time of the incident -Post Accident/Incident Checklist Process: -The Nursing Supervisor/Charge Nurse, Unit Manager and/or the department Director or Supervisor shall promptly be notified and then responsible for assessing, reviewing, documenting and reporting of the incident and/or accident -Internal Reporting of Accidents/Incidents: -Regardless of how minor an accident or incident may be, it must be reported to the Nurse Manager or Nursing Supervisor -Employees witnessing an accident or incident involving a resident, employee, or visitor must report the occurrence to the Nurse Manager or Nursing Supervisor as soon as practical -The supervisor must be informed of all accident or incidents so that medical attention can be provided -Medical Attention, the nurse shall: -Notify the family as soon as possible concerning accident/incident -If the injury appears serious or questionable, the individual will be sent to the hospital by ambulance or 911 as needed -The following data, as applicable, shall be included on the Incident/Accident report form: a. The date and time the incident/accident took place; b. The nature of the injury/accident; c. The circumstances surrounding the incident/accident; d. Where the accident/incident took place; e. The name(s) of witnesses if incident/accident observed; f. The resident or victim's account if applicable; g. Exactly what was observed or heard regarding the accident/incident; h. The time the resident's Attending Physician was notified, as well as the time the Physician responded and his/her instructions; i. The date/time the resident's family was notified and by whom; j. The condition of the resident and his/her vital signs; k. Type of injury; diagram location of injury; l. If first aid was administered; m. The disposition of the resident (transferred to the hospital). If employee (sent home, sent to physician, returned to work, etc.); n. Any corrective actions taken or interventions immediately put in place to prevent further incident; o. Other pertinent data, to include health status information; p. Follow-up information; q. The signature and title of the person completing the report Incident/Accident Statement Form, by RN Supervisor, Charge Nurse, Manager: a. How did you learn of the incident/accident; b. Actions taken; c. List of nursing staff caring for the resident at the time of the incident and one shift prior; d. Resident statement of incident/accident if applicable; e. Was the Physician and family notified; f. Any witnesses (list the names) and was statement completed on the Incident/Accident Form Involved Party Statement Form, which must be filled out completely by the witness, asks questions regarding resident prior to incident/accident, and continence/toileting status. All answers for completion are reviewed by the RN Supervisor/Charge Nurse/Manager; g. All environmental factors reviewed and those applicable chosen (documented) on the form; h. All witnesses to the incident must fill out their own Incident/Accident Involved Party Statement Form. Reporting -If the resident has sustained any suspected or actual significant injury, is sent to the hospital or abuse is suspected, the supervisor/manager must notify immediately the Administrator/Director of Nurses a. The Supervisor/Manager will begin the investigation for root causes of the occurrence -The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall ensure that incident and accident packet is complete and submit the original to the Director of Nursing Services at the end of her shift -The Director of Nursing or designee shall ensure that the Administrator receives a copy of the Incident and Accident Packet -The Director of Nursing or designee shall ensure that all IDCP (interdisciplinary care plan) team members have reviewed the Incident and Accident Packet if applicable -Director of Nursing and Administrator are responsible to review Incident/Investigation and Conclusion to determine if incident requires reporting to outside agencies such as; Department of Health, Office of the Inspector General, Centers for Medicare and Medicaid Services, etc. Evaluation: -All incidents and accidents will be evaluated when applicable by the interdisciplinary team -The team will review the investigation and continue, if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education and conclude the investigation -The team will write an interdisciplinary team note discussing above Resident #53 was admitted to the facility in [DATE] with diagnoses including Parkinson's disease and major depressive disorder. Review of the medical record indicated Emergency Department documentation, dated [DATE], including but not limited to: -Patient presents to the emergency department from nursing home with reported change in mental status. Patient says he/she was given too many medications. Per Emergency Medical Services, the patient received 8 milligrams (mg) of Narcan (opioid reversal agent) which helped arouse him/her. Review of a Nursing Progress Note, dated [DATE], indicated: -At approximately 5:25 P.M., Resident was minimally responsive and confused. Resident was unable to keep his/her eyes opened, skin pale and slurring speech. Unable to get blood pressure. Administered Narcan with no change. 911 called and picked up Resident at approximately 6:10 P.M., Physician notified. Resident was monitored at the hospital for two hours and was sent back to the facility. During an interview on [DATE] at 10:25 A.M., Resident #53 said on [DATE], a 7:00 A.M. to 3:00 P.M. agency Nurse gave him/her the wrong medications. The Resident said he/she was working in the gift shop and usually the Nurse will bring his/her medications to the gift shop, but she didn't this time. When he/she arrived back at his/her room in the afternoon, there was a cup of pills on his/her table and the Resident took them. The Resident said a short time later, the 3:00 P.M. to 11:00 P.M. Nurse came in and gave him/her more medication and not long after that I went out. I couldn't open my eyes and they had to use two doses of Narcan on me and sent me to the hospital. The Resident said either he/she was given someone else's medication or was given too much medication. A few days later when he/she was feeling better (less groggy), the Resident asked to speak to the Administrator to find out what happened, but he/she hasn't heard anything yet, more than seven months after the incident occurred. The Resident said he/she was upset and frustrated at the facility's lack of response and wanted to know what happened. He/she said, I could've died . The surveyor requested to review the Incident/Accident Report and Investigation for the adverse event that occurred on [DATE]. The surveyor was provided a copy of the Grievance/Concern & Comment Form, and not a Incident and Accident Packet. The Grievance form identified the following concern: -Resident went to request to meet with the Administrator on [DATE] regarding an incident that happened Thursday [DATE] with an agency Nurse and medications on the 7:00 A.M. to 3:00 P.M. shift. Review of a memo attached to the Grievance Form indicated the receptionist alerted the Administrator on [DATE] that Resident #53 wanted to speak to him about the incident, wanted to know the name of the agency nurse who gave the wrong medication, and wanted her license pulled so it does not happen to anyone else. Attached to the Grievance Form was a statement obtained from Resident #53 on [DATE] at 11:30 A.M. during a meeting with the Administrator and Social Worker. Review of the statement indicated the Resident did not take his/her 9:00 A.M. medication on [DATE] due to his/her stomach bothering him/her and went to work at the facility store (gift shop). The Resident said he/she forgot to tell nursing staff that he/she would be at the store, and therefore no one brought medication to him/her there, as they usually do. The Resident reported he/she left the store at 4:00 P.M. and returned to his/her room and found a cup of medication left on his/her table, assumed they were his/her morning medication and took them. Shortly after, the 3:00 P.M. to 11:00 P.M. nurse came into his/her room with his/her afternoon/evening medications and the Resident took them. The Resident stated shortly afterward, he/she passed out and one of the other residents found him/her and called the nurse. The Resident stated he/she was given two doses of something, but it did not help. The Resident reported feeling high and his/her eyes were so heavy, he/she could not open them until he/she got to the emergency room . The statement indicated Resident #53 requested an investigation be conducted to find out what medications were left in his/her room because he/she may have received someone else's medication. Further review of the Grievance/Concern & Comment Form indicated it was blank with no investigation, employee statements, conclusion or follow-up with the Resident. During an interview on [DATE] at 3:02 P.M., the surveyor reviewed the Grievance/Concern & Comment form and Resident #53's medical record with the Administrator. He said the [DATE] adverse incident was not a grievance per say, it was more of a medical concern and should have been documented and investigated thoroughly utilizing the Incident and Accident Packet. He said when a mistake happens, it needs to be investigated by clinical staff and rectified and it was not. He said there was no Director of Nursing (DON) in the facility at the time of the incident and it wasn't investigated or reported to any outside agencies according to facility policy. During an interview on [DATE] at 3:34 P.M., the surveyor reviewed the Grievance/Concern & Comment form and Resident #53's medical record with the DON. She said she started working at the facility on [DATE] and did not work at the facility at the time the incident occurred. The DON said that the adverse medication event was found incidentally in the Nursing Progress Notes by the Regional Nurse during routine medical record audits in [DATE]. The DON said that the adverse medication event should have been investigated and said if she worked at the facility at the time of the incident, she would have reported it immediately. Review of the medical record indicated a Therapy Progress Note, dated [DATE], from the facility's consultant Psychiatric service. The therapist indicated Resident #53 displayed observable symptoms of psychosocial distress during the session. The Resident discussed being sent to the hospital after becoming unresponsive and voiced concerns related to the incident. Review of a Therapy Progress Note from the Psychiatric service, dated [DATE], indicated Resident #53 presented as anxious, very weepy, and reported a depressed mood and anxiety related to the incident that resulted in him/her being sent to the hospital. During an interview with Resident #53 on [DATE] at 2:00 P.M., Resident #53 said he/she still gets anxious, weepy, and upset about the medication incident because he/she does not know what happened and is fearful that it could happen again.

Based on observations, interview, and record review, the facility failed to ensure a physician was notified of changes for one Resident (#45) in order to alter the treatment, in a total sample of 21 residents. Specifically, the facility failed to notify the physician of a recommendation to change the treatment for a wound on the right great toe. Findings include: Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated a diabetic ulcer to the right great toe was identified in February 2023. Review of the Wound Evaluation and Management Summary from the consultant wound physician, dated 2/3/23, indicated Resident #45 had a diabetic wound of the right, medial, first toe, measuring 1.2 centimeters (cm) length by 0.4 cm width by 0.1 cm depth with dried fibrinous exudate (scab). The wound consultant made a recommendation to apply Bacitracin (topical antibiotic) to the wound twice daily for eight days and off-load (remove weight or redistribute weight to areas less prone to pressure) the wound to prevent any trauma. Review of the Treatment Administration Record (TAR) for February 2023 indicated that as of 2/4/23, the treatment to the diabetic wound on the left great toe was for Bacitracin twice a day. The order was transcribed incorrectly and indicated treatment was to be applied to the left great toe and not the right great toe. Review of the Wound Evaluation and Management Summary from the consultant wound physician, dated 2/10/23, indicated the wound had deteriorated, measuring 1.2 cm length by 0.8 cm width by 0.1 cm depth with 5% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 95% dermis (the inner layer of the two main layers of the skin). The wound consultant made a recommendation to change the wound treatment to apply Bacitracin once daily for seven days and add a sterile gauze sponge and paper tape daily for 30 days. Further review of the TAR for February 2023 indicated the wound treatment that was initiated 2/4/23 was unchanged. Review of the Nursing Progress Notes failed to indicate the physician was notified of the wound consultant's recommendation to determine if a change to the treatment should be ordered. Review of the Wound Evaluation and Management Summary from the consultant wound physician, dated 2/17/23, indicated the wound had improved, measuring 1.2 cm length by 0.8 cm width by not measurable depth with 5% granulation tissue and 95% dermis. The wound consultant made a recommendation to discontinue the current treatment of Bacitracin once daily and to start Mupirocin ointment (used to treat secondarily infected traumatic skin lesions due to specific bacteria) once daily for nine days and continue sterile gauze sponge and paper tape daily for 28 days. Further review of the TAR for February 2023 indicated the wound treatment that was initiated 2/4/23 was unchanged. Further review of the Nursing Progress Notes failed to indicate the recommendation was reviewed with the physician to determine if a change to the treatment should be ordered. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/24/23, indicated the wound had improved, measuring 1.0 cm length by 0.6 cm width by not measurable depth with 10% granulation tissue and 90% dermis. The wound consultant made a recommendation to continue Mupirocin ointment once daily for eight days and continue sterile gauze sponge and paper tape daily for 21 days. Further review of the TAR for February 2023 indicated the wound treatment that was initiated 2/4/23 was unchanged. During an interview on 3/15/22 at 8:30 A.M., Unit Manager #1 said the current order for treatment was for Bacitracin to the wound twice daily. She said she was not aware if the primary care physician for Resident #45 was notified of the wound Physician's recommendation to make changes to wound treatments. She said the physician should have been notified of the recommendation from the wound consultant to change the treatment.

NOT CORRECTED Based on observations, interviews, and record review, the facility failed to ensure one Resident (#91), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of a pressure injury. Specifically, the facility failed to implement treatments as ordered, notify the physician, and reassess worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to an unstageable pressure area to the Resident's coccyx. Findings include: Review of the facility's policies titled Wound Ulcer, initiated 1/2023, and Wound Treatment Guidelines, last revised 1/2023, indicated the following: -A skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open. -The licensed nurse shall: -Document wounds/skin impairments in the electronic medical record including wound measurements, will reflect if dressing is intact, drainage noted, pain associated with the wound, any odor and condition of surrounding skin which is visual around dressing -Notification of medical provider of new or worsening wound -Refer the wound to wound care specialist or facility medical provider for further evaluation and treatment recommendations Resident #91 was admitted to the facility in November 2022 with diagnoses including Parkinson's disease and acute kidney failure. Review of the 3/16/23 Minimum Data Set (MDS) assessment indicated Resident #91 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15, was frequently incontinent of bowel, was at risk of developing pressure ulcers, and had no unhealed pressure injuries, or other wounds or skin problems. Review of the April 2023 Physician's Orders indicated: -Apply Dermaseptin (barrier cream) to buttocks every shift (10/14/22) -Apply Dermaseptin to buttocks as needed (11/25/22) -May be evaluated and treated by wound Physician (9/14/22) Review of Resident #91's quarterly Norton Scale (a pressure injury risk assessment scale), dated 3/31/23, indicated he/she was at high risk for pressure injury, due to being chairbound, limited mobility, and double incontinence and in fair physical condition. During an interview on 5/9/23 at 12:35 P.M., Unit Manager #1 said while she was on-call over the weekend from 4/21/23 to 4/23/23 (she could not recall which day), she received a call from a nurse caring for Resident #91 to notify her of a new area on the Resident's buttocks. Unit Manager #1 said she told the nurse she would look at it when she came into the facility on Monday. Unit Manager #1 said that the Assistant Director of Nursing must have received a message as well because she saw the Resident on 4/24/23. Review of nursing notes from 4/21/23 to 4/23/23 failed to indicate documentation that a new area had been identified on Resident #91's buttocks and new treatment orders obtained. However, review of the April Treatment Administration Record (TAR) indicated a new treatment for the Resident's upper buttocks of wash with normal saline, pat dry, apply house moisture barrier cream, cover with dry protective dressing, once a day on the 7:00 A.M. to 3:00 P.M. shift was ordered on 4/21/23. The TAR indicated the following descriptions of the area to the Resident's upper buttocks: -4/21/23, pink, intact -4/22/23, pink, fragile -4/23/23, fragile -4/24/23, open, red. Comment: open area 2 centimeters (cm) x 3/4 cm (no depth documented) Review of a 4/25/23 Wound Management Report and a 4/25/23 late-entry nursing note (for 4/24/23) written by the Assistant Director of Nursing (ADON) indicated a new MASD wound was observed to the Resident's right buttock at 5:47 A.M. The wound bed was diffused with irregular edges, pink/no drainage, no odor, and measured 0.75 cm x 2 cm x less than 0.1 cm. The surrounding area was described as clean/dry/intact. The Resident is incontinent of bowel and reported that he/she does not know when he/she is moving his/her bowels. Nursing consulted with the house physician and requested treatment orders. The physician added skin prep around wound to the current treatment order on 4/24/23. The medical record failed to indicate the physician was notified, the Resident was reassessed or referred to the wound Physician when the wound changed from pink and fragile to red and open and the ADON documented her findings on 4/25/23 at 5:47 A.M. During an interview on 5/8/23 at 12:35 P.M., Nurse #1 said when she saw that Resident #91's wound had changed from pink to a beefy red on 4/24/23, she should have written a nursing note and notified the physician. She said she just told the oncoming nurse at the change of shift that day. Further review of the April 2023 TAR indicated: -4/25/23, open, pink -4/26/23, open, pink -4/27/23, treatment not administered, noted that Resident was unavailable -4/28/23, no description of the wound The Resident was not provided wound treatment as ordered on 4/27/23. Review of a 4/28/23 Wound Management Report indicated the Resident's wound appeared to be stable and measured 0.8 cm x 1.7 cm x 0.1 cm with partial thickness, pink wound bed, granulation (the development of new tissue and blood vessels in a wound during the healing process) 100%, no drainage, no odor, irregular edges, diffused. Resident denies pain. Further review of the April 2023 TAR indicated: -4/29/23, right upper buttock stage 1, open, red, no drainage -4/30/23, red, open, no drainage -5/1/23, red, open -5/2/23, red -5/3/23, stage 1, open, red, moderate drainage -5/4/23, treatment not administered The Resident was not provided wound treatment as ordered on 5/4/23. The medical record failed to indicate the physician was notified of the change, the Resident was reassessed for new treatment interventions or referred to the wound physician due to a change in condition of the wound (identified by nursing as a stage 1 wound), remained red, open and developed moderate drainage. Review of a 5/5/23 Wound Management Report written by the ADON indicated the Resident's wound was declining and measured 6 cm x 5 cm x 0.1 cm. The Resident was seen by the consultant wound physician on 5/5/23, 11 days after nursing staff documented a change in condition of the MASD wound that worsened from pink and intact, to red and open. Review of a 5/5/23 Initial Wound Evaluation and Summary from the consultant wound physician indicated Resident #91 has an unstageable pressure wound to his/her coccyx of at least 7 days duration, with moderate serous exudate (a clear, thin, watery fluid). The wound measured 6 cm x 5 cm x 0.1 cm with a surface area of 30 square cm. Treatment recommendations were to treat the wound with Alginate calcium with silver, apply twice daily for 30 days, Superabsorbent gelling fiber with silicone border and apply twice daily for 30 days, Skin prep apply twice daily for 30 days, Vitamin C 500 milligrams (mg) twice daily, and a low air loss mattress. An order for a low air loss mattress set to 200 pounds (lbs.) was initiated on 5/5/23. Review of H & R Healthcare manufacturer's user manual for an IPS Technology low air loss mattress indicated the mattress is to be set according to a patient's weight. Review of Resident #91's weight record indicated the Resident weighed 155.4 lbs. on 4/4/23. The surveyor observed Resident #91 lying in bed supine on an air mattress that was on and set to 200 lbs. on the following occasions: -5/8/23 at 11:50 A.M. -5/9/23 at 9:22 A.M. -5/9/23 at 11:09 A.M. -5/9/23 at 12:10 P.M. -5/9/23 at 4:06 P.M. During an interview on 5/9/23 at 9:35 A.M., the ADON said nursing staff identified the area on Resident #91's buttocks sometime over the weekend of 4/21/23 through 4/23/23 and she found out about the wound on 4/24/23. The ADON said she assessed the Resident on 4/24/23 and the wound was not open at that time. She said she was not notified by nursing later in the day that the wound had opened. The ADON said she next assessed the wound and took measurements on 4/28/23 but did not make a referral to the wound physician. She said the wound physician evaluated the Resident on 5/5/23, and the wound had deteriorated from a MASD to an unstageable pressure ulcer and made treatment recommendations including a low air loss mattress set to the Resident's weight. She said nursing staff are supposed to document daily in the medical record regarding a description of the wound and inform the physician of any changes, but they did not. She said the MASD wound would not have worsened to a pressure ulcer if there was daily documentation to reflect the changes in the wound, the physician was informed of the changes and interventions were implemented timely. During an interview on 5/9/23 at 10:17 A.M., Physician #1 said that he did not know about Resident #91's wound prior to 5/5/23. He said he learned of it when he saw the wound consultant's notes and recommendations. He said he did not know which physician was contacted on 4/21/23 and gave orders for treatment of the MASD. He said he would have ordered interventions earlier in an effort to prevent it from worsening to an unstageable pressure wound if he had known about it.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, whose primary language was Portuguese, but was able to make his/her needs known to staff, the Facility failed to ensure he/she was free from verbal abuse by a staff member. On 12/11/22 at approximately 6:50 P.M., Certified Nurse Aide (CNA) #1 engaged in a verbally abusive altercation with Resident #1, that took place at the Nurse's Station and was witnessed by other staff members. CNA #1 told Resident #1 to shut up, that he/she was a drunk and that was why his/her spouse left him/her. Resident #1 became visibly upset, anxious, agitated, tried to get up from his/her wheelchair to confront CNA #1, and fell . Findings include: Review of the Facility's Policy titled, Abuse, Neglect, Misappropriation, dated effective July 2018, indicated that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of property. The Policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Resident #1 was admitted to the Facility in November 2021, diagnoses included acute respiratory failure with hypoxia, diabetes mellitus, chronic kidney disease stage 3, difficulty in walking, restlessness, agitation and major depressive disorder. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 11/03/22, indicated he/she was cognitively intact. Review of the Facility's Internal Investigation Report, dated 12/13/22, indicated that on 12/11/22, at approximately 6:50 P.M., CNA #1 told Resident #1 to shut up, that he/she was nothing but a drunk and that was why his/her spouse did not want to deal with him/her. The Report indicated that Resident #1 became very upset and anxious, and the next thing he/she was on the floor. The Report indicated that other staff members witnessed CNA #1 argue with Resident #1 (in Portuguese). The Report indicated that the Facility substantiated that altercation as verbal abuse. During an interview on 12/20/22 at 12:50 P.M., Resident #1 said that CNA #1 told him/her to shut up and go to my room. Resident #1 said that CNA #1 called him/her a drunk and said that is why your spouse left you. Resident #1 said that he/she got so anxious, nervous and worked up, that he/she tried to get up from the wheelchair and fell . Resident #1 said that CNA #1 was very disrespectful and offended him/her which caused him/her increased anxiety because of his/her nerves. Review of Nurse #1's Written Witness Statement, dated 12/11/22, indicated that Resident #1 was upset, yelling, and CNA #1 was talking to him/her. The Statement indicated that she asked CNA #1 to leave Resident #1 alone. The Statement indicated that Resident #1 was swinging his/her hands around his/her head, trying to get out of the wheelchair while yelling at CNA #1 in frustration, when he/she lost his/her balance and fell out of the wheelchair. The Statement indicated that Resident #1 stated that CNA #1 called him/her a drunk, as translated by the housekeeper. During an interview on 12/28/22 at 9:52 A.M., Nurse #1 said that Resident #1 and CNA #1 were arguing in Portuguese. Nurse #1 said she asked CNA #1 to walk away from Resident #1, but CNA #1 do not leave the area. Nurse #1 said that CNA #1 kept arguing with Resident #1 and said she (CNA #1) was triggering and agitating him/her. Nurse #1 said that as CNA #1 continued to argue with Resident #1, Resident #1 was yelling at CNA #1 and swinging his/her arms at CNA #1. Nurse #1 said Resident #1 tried to get out of the wheelchair during the altercation and fell . Nurse #1 said that Resident #1 was upset, agitated, and frustrated with what CNA #1 said to him/her. Nurse #1 said that CNA #1 caused Resident #1 emotional harm. Nurse #1 said she asked the Housekeeper (who also spoke Portuguese) to translate what Resident #1 said. Nurse #1 said the Housekeeper said that Resident #1 said that CNA #1 called him/her a drunk and that is why his/her spouse left him/her. Nurse #1 said that CNA #1 triggered Resident #1 to the point that he/she fell out of the wheelchair in frustration and said CNA #1 continued to argue with Resident #1 even after he/she fell . During an interview on 12/21/22 at 1:30 P.M., (which included review of her written witness statement), the Housekeeper said that Nurse #1 asked her to translate for her what Resident #1 said. The Housekeeper said that Resident #1 was visibly very upset and said in Portuguese that CNA #1 called him/her a drunk. Review of CNA #2's Written Witness Statement, dated 12/11/22, indicated that when she was giving CNA #1 her assignment, Resident #1 was yelling. The Statement indicated that CNA #2 heard CNA #1 tell Resident #1 to shut up and that CNA #1 and Resident #1 were going back and forth. The Statement indicated that she (CNA #2) asked Resident #1 what was going on and that Resident #1 told her that CNA #1 called him/her a drunk. During an interview on 12/20/22 at 2:46 P.M., CNA #2 said that CNA #1 and Resident #1 were arguing in Portuguese and that CNA #1 told him/her to shut up. CNA #2 said that Resident #1 was visibly upset, anxious, and stood up from the wheelchair, and was about to fall when she was able to eased him/her to the floor. CNA #2 said that CNA #1 continued to argue with Resident #1 even when he/she was on the floor. CNA #2 said that Resident #1 was visibly and emotionally upset with what CNA #1 was saying to him/her. CNA #2 said that she did not understand Portuguese and said that she asked Resident #1 what CNA #1 said and that he/she told her that CNA #1 called him/her a drunk. Review of the Social Worker's Written Witness Statement, dated 12/12/22, indicated that she met with Resident #1 about an inappropriate interaction with CNA #1. The Statement indicated that Resident #1 said that CNA #1 told him/her to shut up, go to his/her room, no one likes you, you are a drunk, that is why your spouse does not want to deal with you, and your family does not like you. The Statement indicated that Resident #1 became so upset and said this was not good for him/her or his/her nerves. The Statement indicated that Resident #1 said he/she did not know what happened but that he/she was so worked up that he/she fell out of the wheelchair. During an interview on 12/20/22 at 2:10 P.M., the Social Worker said that she was notified that a CNA said inappropriate comments to Resident #1 and said that she interviewed him/her with a Portuguese translator. The Social Worker said that Resident #1 told her that CNA #1 told him/her to shut up, go to his/her room, that nobody likes him/her, and that his/her spouse left him/her because he/she was a drunk. The Social Worker said that Resident #1 said he/she was upset and agitated at what CNA #1, and that he/she started to wave his/her hands and fell out of the wheelchair. During an interview on 12/20/22 at 2:25 P.M., the Director of Nurses (DON) said that after their investigation was completed, the Facility substantiated the altercation as verbal abuse and said that CNA #1 resigned on the day of the altercation and was terminated.

Based on observation, record review and interviews the Facility failed to ensure that allegations of neglect were immediately reported and investigated or two sampled Residents (#7 and #16) from a total sample of 24 Residents and 4 Non-Sampled (NS) Residents (NS#3, NS#4, NS#5 and NS#6) out of 7 Non-Sampled Residents. Findings include: Review of the Facility's Abuse Policy indicated that all alleged violations involving abuse, neglect, exploitation, and/or misappropriation of Resident property will be thoroughly investigated by the Facility under the direction of the Administrator and reported all alleged violations to the Department of Public Health (DPH). The investigation is to include statements from all staff who was working on the unit, suspension of any employee suspected of abuse, neglect, or mistreatment immediately pending the completion of the investigation. 1.) Resident #16 was admitted in 6/2015 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of 15 on his/her Brief Interview of Mental Status (BIMS), indicating he/she was capable of making decisions. The Resident's hearing, vision and ability to communicate was more than adequate and the Resident did not exhibit any mood or behavioral symptoms. The MDS indicated the Resident was continent of bowel and had occasional bladder incontinence and required extensive assistance in activities of daily living, but could ambulate with limited assistance of one staff. During the Group Interview on 6/22/17 at 2:00 P.M., multiple Residents, including Resident #16 stated their frustration with what they said was inadequate staffing. Resident #16 said that he/she felt staffing was insufficient and that complaints were not addressed. Resident #16 requested to meet with the Surveyor to discuss additional concerns. On interview with Resident #16 on 8/23/17 at 2:10 P.M., he/she asked to speak in a private setting. Resident #16 was alert, oriented. During the interview, Resident #16 stated that he/she was more than frustrated with the Facility's problems with low staffing and said that the Staff had neglected him/her. Resident #16 stated when staff failed to provide care he/she ended up wetting him/herself and then was left sitting in wet and soiled clothing for 3 hours. Resident #16 stated that on 8/21/17, between 4:00 P.M. to 4:30 P.M., he/she put on the call bell for toileting. The Resident stated that he/she cannot toilet self for multiple reasons, but can with assistance of staff. The Resident stated he/she waited for 45 minutes and then went and asked for care from the Nurse on duty. The Resident said that the Certified Nursing Assistants (CNAs) were busy and that neither the CNA assigned to him/her nor the Nurses he/she asked for help provided assistance. The Resident stated that after no assistance was provided and that he/she unfortunately wet him/herself. Resident #16 stated that if staff had assisted him/her the new pants he/she was wearing would not be soiled and he/she would have not become so upset. Resident #16 stated no care was provided for up to 3 hours and that he/she was left in the wet and soaking pants, sitting in his/her wheelchair. The Resident stated he/she did not receive any care or assistance until after 9:00 P.M. The Resident stated that he/she could identify the CNA assigned to him/her and the Nurse he/she had complained to. The Resident stated that he/she had experienced other problems associated with low staffing in the past, but that this was more than he/she could accept and felt neglected. The Resident stated that he/she wore briefs for protection against occasional bladder dysfunction, but that he/she knew when he/she felt the need to void. Resident #16 stated he/she reported the complaint to the Social Worker on 8/22/17. Resident #16 stated the Social Worker wrote down the complaint, but that no Facility staff had had followed-up with him/her. Resident #16 said that he/she was not only upset about sitting in wet soiled pants for 3 hours, but that staff ignored him/her and caused him/her to act out (yelling and hollering). Resident #16 said that he/she fears that things won't change and that he/she will not get his/her needs met. Record review on 8/23/17 failed to indicate the Resident had voiced a complaint (and was heard yelling and hollering) on 8/21/17 or 8/22/17. On interview on 8/24/17 at 1:20 P.M. and 4:00 P.M., the Social Worker stated she had received a complaint from Resident #16. She said that the Resident stated that he/she wet self, after not receiving care on 8/22/17 and then was left sitting in soiled and wet pants for 3 hours. The Social Worker said she wrote out the Resident's statement and gave the statement to the Director of Nurses on 8/22/17. The Social Worker said she would provide a copy of the Resident's statement to the Surveyor and speak with the Director of Nurses for additional information about the investigation. The Social Worker said that she had not spoken with the Resident since she received the Resident's complaint on 8/22/17. On 8/24/17 at 2:10 P.M., the Social Worker provider a copy of the Resident's statement that had been reported to her on 8/22/17 at 9:45 A.M. Review of the statement indicated that it was completed on a Facility Investigation Statement not on a Grievance Form. The statement coincided with the report the Resident stated to the Surveyor on 8/23/17. The statement indicated the Resident put on the call light to use the bathroom and was left so long that he/she wet self. The statement indicated the Resident asked for help from the Nurse, who did not assist the Resident. The Resident was able to describe the CNA and said that the CNA has left the Resident without providing care in the past and that he/she no longer wanted the CNA to provide future care. In addition, the Resident asked that the Administrator and Director of Nurses (DON) be notified so it can be straightened out. The Social Worker stated she then gave the investigation statement to the DON to address. The Social Worker added that she had spoken with the DON to obtain her investigation. She said the DON stated she had met with the Resident and taken care of it. The Social Worker was unaware of the outcome of the complaint. On 8/25/17 at 8:30 A.M., the Surveyor followed-up with Resident #16. During the interview the Resident said that no Facility staff had met with him/her after he/she reported his/her complaint to the Social Worker on 8/22/17. On interview with the DON, on 8/25/17 at 9:30 A.M., she stated that she met with Resident #16 right after the Social Worker notified her of the Resident's complaint. She said the Resident stated that the CNA caring for him/her would come in and out of the room during care and that he/she preferred to have the care started and completed. The Resident stated he/she would like the regular' staff to care for him/her and did not feel neglected. The DON provided a copy of the Investigation Statement she completed with the Resident on 8/22/17 at 10:15 A.M. and copies of the 3:00 P.M. to 11:00 P.M. CNA assignment sheet for 8/22/17, the daily schedule dated 8/21/17, an updated care plan dated 8/22/17, an undated statement from a Nurse and an undated and unsigned piece of paper outlining what was done about the Resident's complaint. Review of the documents indicated the DON met with the Resident in his/her room regards to concerns voiced to social worker. The statement indicated the Resident discussed per diem staff care compared to regular staff care. The Resident was not asked about the Resident's report of neglect, but the statement indicated the Resident was asked if he/she felt neglected. The DON indicated the Resident said no, it was just that the per diem staff do not know me like the the regular staff. The information provided did not indicate the DON spoke specifically about the Resident's report of neglect that had occurred on 8/21/17. The Nurse's statement indicated that Resident #16 had complained last week about newer staff not knowing his/her care needs like the aides who have been here longer. The care plan was updated to include consistent assignment and preference for regular staff to care for him/her. During review of the investigation and interview on 8/25/17 at 9:30 A.M., the DON stated she had not asked the Resident directly about his/her complaint that was made to the Social Worker. She said that she wanted to allow Resident #16 to report his/her concern in his/her own words and without her input. The DON said the Resident talked about new staff and preferring regular staff rather than per diem staff. The DON said when the Resident did not state she was neglected or state that he/she was left in wet and soiled clothing for 3 hours, she asked if the Resident felt safe or felt neglected. The DON said that the Resident stated he/she felt safe. The DON could not explain how she could complete an investigation of an allegation without confirming the Resident's statement as outlined in the Resident's grievance. The DON said that her interview was to ensure the Resident felt safe talking with her and to create a rapport. Subsequently, the Surveyor met with the Resident on 8/25/17 at 12:15 P.M. and 12:50 P.M. in an attempt to verify if the Facility had taken action to investigate the Resident's allegation of neglect. The Resident was articulate and able to recall all visits with the Surveyor and all his/her accounting of the incident. The Resident said that no staff had discussed the allegation of neglect with him/her other than her discussion with the Social Worker and the Surveyor. The Surveyor observed the DON encounter with the Resident at 1:10 P.M. The Resident stated he/she knew the DON, but did not know that she was the DON. The Resident stated he/she did meet with the DON, but as previously stated did not know that she was investigating his/her complaint. Resident #16 said the DON asked about the staff and if he/she felt safe with them and his/her preference of regular staff. During a final discussion with the DON on 8/25/17 at 1:10 P.M., the DON stated that she had not discussed the specifics of the allegation with the Resident and had not reported the allegation of neglect because the Resident had answered no to her question. the facility failed to fully investigate and finalize the allegation of neglect by not inquiring specifically about the Resident's grievance. 2. For Resident #7, the facility failed to investigate an allegation of neglect related to failure of nursing staff to respond to complaints of pain for more than a 4 hour period, failed to protect the Resident, and failed to report an allegation of neglect to DPH as required. Review of the investigation statement dated 7/19/17, indicated that Resident #7 alerted the nurse at 2:00 A.M. that he/she was in pain and requested medication. At 4:30 A.M., the Resident again asked the nurse for pain medication and did not receive it. At 5:45 A.M., the Resident again told the nurse that he/she was in a lot of pain and had been waiting for pain medication all night. The nurse then brought medication to Resident #7 at 6:00 A.M At 6:05 A.M., the nurse alerted the Resident that he had not given him/her [MEDICATION(S)], but had given an antibiotic medication by mistake. Review of the narcotic log indicated that the Resident was not administered [MEDICATION(S)] until 1:15 P.M. on 7/19/17. 3. For NS Resident #3 the Facility staff failed to investigate an allegation of mistreatment/neglect, and failed to report the allegation to DPH as required. A review of an investigation statement dated 7/21/17, indicated that the Resident reported to the facility social worker that 2 CNAs (certified nursing assistant) denied his/her request for cola to drink as well as his/her request for a nebulizer treatment. The Resident also reported to the social worker that one of the CNAs was mimicking him/her by putting her fingers in her mouth. Additionally, the Resident reported that one of the CNAs told him/her that they had disconnected the call light from the wall so he/she could not use it. 4. For NS Resident #4, the Facility staff failed to investigate a report of mistreatment, failed to protect the Resident, and failed to report the allegation to DPH as required. Review of an investigation statement dated 6/9/17, indicated that the Resident reported that a staff nurse had performed a wound dressing change incorrectly earlier in the week. The Resident reported that when the he/she brought it to the nurse's attention, the nurse became frustrated, raised her voice to the Resident and abruptly left the room. The Resident reported that the following day, the same nurse performed the dressing change incorrectly again. The Resident reported that he/she was nervous to say anything to her. The report indicated that the Resident told the Administrator that he/she did not want to have that nurse again because sometimes she can yell, and I've had to take more medication for my nerves because of it. 5. For NS Resident #5, the Facility staff failed to investigate a report of mistreatment, failed to protect the Resident, and failed to report the allegation to DPH as required. Review of the grievance/concern form and attached investigation statement dated 6/7/17, indicated that NS #5 reported that a CNA refused to assist him/her after having an episode of vomiting and said in the presence of the Resident, I don't do vomit, put her hands up in the air and walked away. NS #5 said that he/she was upset and began to cry. The Resident also reported that staff refuse to assist him/her with cleaning his/her teeth. 6. For NS Resident #6, the Facility staff failed to investigate and report an allegation of mistreatment. Review of a grievance/concern form dated 6/8/17 indicated that NS Resident #6's family member reported that earlier in the week during dinner, a CNA threw a dining tray at the Resident while he/she was seated at the table in the dining room which upset the Resident. The family member was not present, but learned of the incident from another Resident that witnessed it.

Based on record review, staff interview and policy review, the facility failed to monitor and evaluate interventions to promote the healing of pressure ulcers for 2 Residents ( #13 and #19), from a total sample of 24 Residents. For Resident #19 with a facility acquired pressure injury, the facility failed to assess, monitor and develop a plan of care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The Facility's Wound Care policy and procedures documents the facility will manage, track, trend, assess, treat, and monitor all facility wounds regardless of origin, and provide education to staff and prevent deterioration of current wounds. All wounds will be seen on weekly wound rounds and have its own tracking sheet to assess progress or decline as well as appropriateness of treatments. Weekly Wound sheet to be completed by nursing will have information for the wound assessment. The information will include the wound site, type/stage, measurements, drainage, odor, condition of wound base, edges and progress or decline of the wound. The policy also indicated the nurse is responsible to establish an individualized plan of care. 1. For Resident #13, the facility failed to prevent an infection of the Stage 4 right heel pressure injury. Resident #13 was admitted in 7/2017 for short term rehabilitation services from an acute care hospital, after a long course of antibiotic care, wound care and [CONDITION(S)]. A review of the hospital discharge information dated 7/12/17 indicated the Resident has had longstanding diabetes resulting in PVD ([CONDITION(S)]) and end stage renal disease and has received [CONDITION(S)] for 8 years. The information indicated prior to this hospitalization underwent an angioplasty and he/she developed a right heel ulcer and [CONDITION(S)]. The Resident was admitted to the facility with a Stage 4 right heel pressure injury ( resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Sheet (MDS) assessment, dated 7/26/17, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (no cognitive impairment) with mood symptoms of feeling down and sleeping issues and no behavioral problems. The assessment indicated the Resident needed extensive assistance for ambulation, transfers, dressing, toilet use and personal hygiene and assessed to be occasionally incontinent of urine. The MDS assessment noted the Resident had one unhealed Stage 4 pressure injury that measured a length of 2.0 cm. (centimeters) by a width of 1.3 cm and a depth of 0.3 cm. The assessment indicated a decision to proceed to care planning. A review of the plan of care dated 7/12/17 had a general category of pressure ulcer indicating the Resident's risk for pressure ulcers, but had no information of the Resident's Stage 4 pressure injury with interdisciplinary approaches for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician's monthly orders for the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. - 11:00 P.M. shift. Monitor every shift for signs and symptoms of infection and intactness of dressing, every shift. There was no evidence in the Resident's medical record that all wounds were seen on weekly wound rounds and had it's own tracking sheet to assess progress or decline as well as appropriateness of treatments per the facility's wound care protocol. During interview and record review on 8/24/17 at 7:35 A.M., the Assistant Director of Nursing (ADON) said the Resident was not included in the weekly rounds due to the Resident being seen by an outside Wound Clinic. During interview on 8/25/17 at 9:30 A.M., the Unit Nurse Manager #1 said she has never done wound measurements because the wound was measured at the Wound Clinic. A review of the Wound Clinic documentation indicated the Resident was seen five times and included information of wound care treatments, assessment of the Stage 4 pressure area and recommendations for dressing changes and what the nursing staff should monitor. The Stage 4 pressure injury was measured at the clinic with recommendations as follows: - On 7/14/17 the clinic report documented the Stage 4 pressure wound measured a length of 2.0 cm with a width of 1.5 cm and a depth of 0.3 cm and listed the treatment order to use a Mepore dressing and the facility used permafoam dressing. The clinic also wanted the facility to apply skin prep to the right heel. The medical record had no documentation of having used the skin prep to the right heel from this appointment time to the time of Surveyor wound observation on 8/25/17. - On 7/21/17 the clinic report documented the Stage 4 pressure wound measured a width of 2.0 cm with a length of 1.3 cm and a depth of 0.3 cm. these measurements were identical to the MDS assessment of the wound. The facility had not measured the wound since admission 9 days earlier and as outlined in the wound protocol. - On 7/28/17 the clinic report documented the Stage 4 pressure wound measured a width of 1.8 cm with a length of 1.2 cm and a depth of 0.2 cm. The clinic recommended to use Mepore (a border gauze dressing) and do not use the foam dressing due to maceration of the wound. There was no information to review if the Physician was notified of this recommendation. - On 8/2/17 the clinic report documented the Stage 4 pressure wound was macerated and again informed the facility to stop using the permafoam dressing that causes maceration of the wound and to use Mepore (a border gauze dressing). - On 8/16/17 the clinic report documented the Stage 4 pressure wound presented with green exudate and to please monitor and if this persists to consult Infectious Disease as this Resident has a history of [CONDITION(S)]. The pressure wound increased size to a length of 2.0 cm with a width of 0.9 and a depth of 0.3 cm. A review of the treatment records for July 2017 indicated the pressure injury had changes with the wound drainage. The treatment records indicated the following: - After returning from a hospitalization on [DATE] for a left orbital fracture, the pressure wound on 7/21/17 had yellow green drainage documented by the nurse. The dressing change documented on 7/24/17 and on 7/26/17 that the wound had purulent drainage. Another 3 days later the wound dressing documentation on 7/30/17 indicated tan drainage. There was no information in the record that the Physician or the Wound Clinic was notified of the changes with purulent drainage. -The treatment record for August 2017 indicated that after 8/16/17, the facility was asked to monitor for infection due to green drainage observed at the wound clinic. The treatment records dated 8/18/17 and 8/22/17 both had notes of the wound having green drainage and there was no information of these documented observations on report to the infectious disease physician or the primary care physician. On 8/25/17, at 10:12 A.M. Surveyor #3 and the ADON observed Staff Nurse #1 change the heel wound dressing. When Staff Nurse #1 removed the Una boot, the wound dressing was stained and dated as last changed on 8/20/17 (5 days earlier). The Resident was asked when the heel dressing was last done and replied it was done yesterday. Once the heel dressing was gently pulled away from the wound there was a foul odor from the wound and the old dressing had a moderate amount of green drainage. The upper wound skin was macerated with a greenish tint discoloration. The Staff Nurse and the ADON measured the wound and found it had increased in size to a length of 3.0 cm with a width of 2.5 cm and a depth of 0.2. The wound was observed to have a pinpoint opening in the center of the wound. The Wound Clinic had given the facility many recommendations for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had not initiated the skin prep to the right heel, the staff were using the wrong dressing cover (that was not according to clinic recommendations), causing the wound to have maceration of the wound edges. Due to the Resident's history of [CONDITION(S)] of the right heel, the facility had on two occasions noted green drainage, but were not reported to the infectious disease doctor or the primary care physician as the clinic had outlined on the 8/16/17 report. The facility had not followed their own Wound Care protocol that included the measurement, tracking and assessment of the wound. The facility's policy did not include directions for monitoring when residents are followed outside the facility for wound care. Part B: Coccyx wound For Resident #13 the treatment records for 7/2017 and 8/2017 indicated the Resident had a pressure injury on the coccyx described on admission as slightly red and excoriated and a treatment to apply [MEDICATION(S)] twice daily. A review of the treatment record notes for July 2017 and August 2017 described the skin as intact but being red. The coccyx area was not staged as a one and the plan of care had no information of this wound. The facility had not developed any approaches/interventions for the care prevention, doing wound measurements, etc. During record review and interview on 8/24/17 at 7:35 A.M., the ADON said this area should have been staged, measured and care planned and said she was not aware of the Resident having this coccyx wound. Interview with Unit Nurse Manager #1 on 8/25/17 at 9:30 A.M. said she never measured the wound and was not aware the Resident had a coccyx injury and treatment. 2. For Resident #19, the facility failed to follow the Wound Care Protocol resulting in a facility acquired pressure wound. The facility failed to the Stage the wound, measure and had not developed a plan of care for the pressure injury. Resident #19 was admitted ,d+[DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS assessment dated [DATE], the Resident had a BIMS score of 12 out of 15 (moderate cognitive impairment) and needed extensive assistance with 2 staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment indicated the Resident did not ambulate and had range of motion limitations for both sides of the upper extremities and one side of the lower extremity. The MDS assessment noted the Resident was frequently incontinent of urine and was at risk of developing pressure ulcers. The MDS documented the Resident had no pressure injuries and the care area was triggered for further assessment and the decision made to proceed to care planning. A review of the plan of care dated 7/21/17 indicated a plan developed for the Resident's risk of developing a pressure ulcer due to his/her immobility, deconditioning, right [CONDITION(S)] and urinary incontinence. The medical record indicated the Resident developed an open area on 8/8/17 and the nurse noted the area on the left upper gluteal cheek as well as the gluteal folds. A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed a skin integrity event document dated 8/9/17 and noted in the evaluation note that the Resident had a Stage 2 open area on the left gluteal buttock and gluteal fold. The report noted the Resident is turned and repositioned every two hours and changed. The document indicated that the Resident has had multiple [CONDITION(S)] (cerebral vascular accidents) and condition is poor. A change in the wound treatment was done on 8/9/17 and noted to wash the area with normal saline, dry well, and cover with island dressing daily on 7:00 A.M. - 3:00 P.M. shift. A review of the nurses treatment record had no information of measuring the wound area to assess and evaluate the healing of the wound area. The facility failed to develop a plan of care for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview and record review on 8/24/17 at 7:35 A.M., the ADON said the wound should have had wound measurements and should have had a plan of care developed for the pressure wounds. 11/29/2017: Per October 2017 IDR review, Resident #6 was removed.

Based on records reviewed and interviews, for 1 of 3 sampled Residents (Resident #1), the Facility failed to arrange for Resident #1's nebulizer machine (inhalation treatment machine) to be delivered to his/her residence and instead discharged Resident #1 with a prescription for a nebulizer machine which Resident #1 was unable to obtain from a pharmacy or a Durable Medical Equipment provider. Within three days after discharge, Resident #1 developed severe shortness of breath, was transported to the hospital by the fire department, and admitted to the hospital with [REDACTED]. Findings include: Resident #1's [DIAGNOSES REDACTED]. Resident #1's MDS indicated he/she received [MEDICATION NAME] sulfate 2.5mg (milligrams) / 3 ml (milliliters) inhalation treatments via a nebulizer machine four times daily. The Facility's Policy and Procedure, titled Durable Medical Equipment , dated September 2015, indicated the Case Manager will coordinate Durable Medical Equipment devices necessary for a patient's discharge back to the community; obtain physician's orders [REDACTED]. location and coordinate with the patient for the arrival of the Durable Medical Equipment. A Case Management Progress Note, dated 6/3/16, indicated Resident #1 had a [DIAGNOSES REDACTED]. A Nurses Progress Note, dated 6/8/16, indicated Resident #1's oxygen saturation (level of oxygen carried by red blood cells through the arteries and delivered to internal organs) level was 88% on room air and increased to 92% during nebulizer treatment and increased to 95% post nebulizer treatment. A physician progress notes [REDACTED].#1 required the use of nebulizer machine for treatment of [REDACTED]. A Case Management Progress Note, dated 6/9/16, indicated Resident #1 was being discharged home with a nebulizer machine prescription and was informed to bring it to the pharmacy on the way home. A Post-Discharge Plan of Care Form, dated 6/9/16, indicated Resident #1 was discharged home with a physician's orders [REDACTED]. The Surveyor interviewed Case Manager #1 at 12:30 P.M., on 10/21/16. Case Manager #1 said Resident #1 did not need the nebulizer and he/she demanded the nebulizer be ordered upon discharge. Case Manager #1 said he discharged Resident #1 with a prescription for a nebulizer machine and informed her/him to bring it to the pharmacy on the way home. Case Manager #1 said he faxed Resident #1's medical necessity documentation for the nebulizer machine to the medical supply provider but it was denied. Case Manager #1 said he never followed up with the medical supply provider and did not know if Resident #1 received the nebulizer machine. The Surveyor interviewed the Medical Supply Provider's Representative at 3:29 P.M., on 10/24/16. The Medical Supply Provider's Representative said that there was no documentation in their electronic system for Resident #1. The Medical Supply Provider's Representative said the Facility should have faxed Resident #1's Physician's Progress Note and Prescription for a nebulizer machine to them so that arrangements could have been made to have the nebulizer machine delivered to Resident #1's residence upon discharge from the Facility. The Surveyor interviewed both the Director of Nurses and the Administrator at 4:20 P.M., 10/21/16. Both the Director of Nurses and Administrator said they did not know why the pharmacy did not dispense the nebulizer machine to Resident #1 upon discharge and the facility did not have the means to discharge Resident #1 home with a nebulizer machine because the facility rents equipment from the medical supply provider and did not have any nebulizer machines to send home with Resident #1. The Surveyor interviewed Pharmacist #1 at 11:30 A.M., on 10/24/16. Pharmacist #1 said that the pharmacy does not carry nor dispense nebulizer machines and only dispenses the medication to be administered via the nebulizer machine. Pharmacist #1 said that he referred Resident #1's family member to a medical supply company to obtain the nebulizer machine. A Hospital Discharge Summary, dated 6/14/16, indicated Resident #1 was admitted on [DATE] with progressively worsening shortness of breath and [MEDICAL CONDITION] exacerbation from not receiving his/her nebulizer medication upon discharge from the Skilled Nursing Facility on 6/9/16. A Social Services Follow up Progress Note, dated 6/16/16, indicated Resident #1 stated that he/she could not get the nebulizer machine and the nebulizer medication when she was discharged home from the Facility on 6/9/16, he/she became sick and was admitted to the hospital. A Hospital emergency room Note, dated 6/12/16, indicated Resident #1 did not receive his/her nebulizer medication for 3 days after being discharged from the Facility and was readmitted to the hospital with [REDACTED].

Based on record review, staff interview and observation for 1 resident ( #11) of 3 residents in the sample who developed pressure ulcers following admission, the facility failed to provide timely, accurate and appropriate wound care management in accordance with accepted standards of clinical nursing practice in order to promote healing and prevent infection. The total sample of residents was 24. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage a to the "Nursing 2011 Drug Handbook" for accepted standards in regards to proper medication administration along with nursing considerations of drug administration issues. Findings include: Facility nurses failed to implement a pressure ulcer treatment from 11/15/11 to 11/21/11, failed to obtain a physician's order for a pressure ulcer treatment that was done on 11/18/11, failed to follow up on recommendations made for a pressure ulcer treatment on 11/18/11 and failed to complete a comprehensive wound assessment when the resident returned from the hospital on [DATE]. Resident # 11 was admitted to the facility for rehabilitation following hospitalization for a hemorrhagic [MEDICAL CONDITION], Gastrostomy tube (feeding tube) placement and dehydration (11/21/11). Per review of the nurses' notes on 11/15/11, the 7-3 shift nurses indicated the resident experienced a change in status. A previously identified skin tag on the resident's back was noted to be a bleeding open area. The resident's left buttock was also assessed with [REDACTED]." No treatment was implemented for the area. On 11/18/11, the Wound Team Leader assessed Resident #11 coccyx area as a stage II pressure ulcer that measured 1.5 cm (length) x 1.0 cm (width) x 0.5 cm (depth) with minimal serous drainage. The wound edges and surrounding tissue were assessed as "healthy, not the macerated wound edges and periwound [DIAGNOSES REDACTED] assessed by the nurse the previous night. The 11/18/11 Wound Leader's Focus Note documented that the coccyx pressure ulcer was cleansed, wound gel applied and covered with perma foam dressing. "Resident will be monitored for progress by the wound team." No physician's order for the treatment was obtained.Per review of the 11/18/11 Treatment Administration Record, the facility failed to implement the recommended treatment orders for the coccyx wound. The Wound Team Leader and Unit Manager #3 reviewed the TAR and physician orders with the surveyor on 11/30/11 at approximately 9:30 A.M. and confirmed that the resident never received the treatment recommended by the Wound Team on 11/18/11. The Wound Team Leader said that the TAR indicated that Resident #11's coccyx and buttock wound was treated with Dimethicone from 11/19 through 11/21/11.On 11/20/11, the 7-3 shift nurse documented a deterioration in the wound status." Areas to the coccyx open. Red center with minimal slough, positive bleeding. Size of dime. Positive foul smell. Smaller area to the right of coccyx superficial pink." The Nurse Practitioner visited the resident on 11/20/11. The Nurse Practitioner documented that the resident had "detection of [DIAGNOSES REDACTED]tous, coccygeal wound described as foul smelling with yellow slough." A wound culture, urine culture and blood work was ordered. The resident was hospitalized from [DATE] until 11/25/11 for treatment of [REDACTED]. On 11/25/11, the day the resident returned to the facility, the pending wound culture report sent to the facility revealed that the resident's coccyx wound was infected with "heavy growth" staphylococcus aureus and heavy growth diptheroids. (infection of the coccyx wound) On 11/25/11 at 3:30 P.M., the Admission nursing assessment revealed a body diagram that identified an "open area" on the buttocks and a "ulcer" on the coccyx. The nurse documented: "patient has stage 2 pressure ulcer on coccyx - (treatment) in place." A treatment for [REDACTED]. The Wound Team Leader said on 12/5/11 at 4:00 P.M., that a comprehensive wound assessment was not completed at the time of readmission. Review of the 11/30/11 Wound Team assessment provided on 12/5/11, indicated that Resident #11's coccyx wound revealed a deterioration in the wound status with increased (length) 1.6 cm x (width) 1.4 cm x (depth) 0.1 cm in wound size and evidence of inflammation of the wound edges and surrounding tissues. The 11/30/11 assessment also indicated deterioration in the buttock wound with inflammation noted on wound edges and surrounding tissue. On 12/5/11 at 4:00 P.M., the Wound Team Leader said that the Wound Team made no recommendations for changes in wound management on 11/30/11 even though both of Resident #11's wounds were assessed as deteriorated and that the coccyx wound cultured positive for wound infection on 11/25/11. The facility failed to address the decline in the wound(s) nor did they communicate these changes to the physician. Please refer to F 314

Based on record review, staff interview and observation for 1 (#11) of 3 sampled residents who developed pressure ulcers following admission, from a total of 24 sampled residents, the facility failed to provide timely and appropriate care to prevent the development of pressure ulcers. When the resident developed a pressure ulcer, the facility failed to implement timely and appropriate treatment and services to promote healing, prevent infection and prevent new sores from developing. Findings include: Resident # 11 was admitted to the facility for rehabilitation following hospitalization for a hemorrhagic [MEDICAL CONDITION], Gastrostomy tube (feeding tube) placement and dehydration. Review of the 11/14/11 initial minimum data set (MDS) assessment indicated that the resident was cognitively intact and dependent on staff for all activities of daily living including bed positioning. The resident was incontinent, was coded with a Foley catheter and received all nutrition via the [DEVICE]. The resident was not identified with pressure or skin areas. On 11/4/11, the resident was assessed at risk for skin breakdown with a Norton Scale Risk Assessment score of 10 indicating at high risk for skin breakdown. A Skin Care Plan was in place. The care plan had a list of potential pressure relieving interventions. The use of a house mattress and a blue foam wheelchair cushion were selected. A low air loss mattress was not selected. The plan indicated to provide consultation as needed by the facility contracted wound consultants. According to the facility "Protocol for Residents at Risk for Pressure Ulcer Development," a Resident who scores 15 or below will be provided specialized interventions that include the use of a pressure reduction mattress replacement or an overlay on the bed. This was not done and the resident was placed on a regular house mattress. Per record review, on 11/15/11, the 7-3 shift nurses documented that the resident's left buttock was red and fragile. The nurses' note indicated, "Wound team made aware." There was no documented evidence that the resident was seen by the wound team. Between 11/15/11 and 11/18/11 there was no documentation regarding the resident's skin. On 11/18/11 at 2 A.M., the 11-7 nurse wrote in the nurses' notes that the resident had "2 stageable pressure areas." The first area, was assessed as a round left buttock wound with a length and width measurement of 1.5 centimeters (cm). The wound edges were assessed as rolled and the periwound was coded as denuded (loss of outer layer of skin) with [DIAGNOSES REDACTED] (reddening of the skin). The second area, was assessed as a stage II coccyx wound with a measured length 0.5 cm and width 0.25 cm. The wound edges were assessed as macerated (softening and whitening of the skin due to moisture), the drainage was coded as small sero-sanquainous, and the periwound coded as [DIAGNOSES REDACTED] (reddened). On 11/18/11, the Wound Nurse assessed Resident #11's coccyx area as a stage II pressure ulcer that measured 1.5 cm (length) x 1.0 cm (width) x 0.5 cm (depth). Further assessment revealed minimal serous drainage. The wound edges and surrounding tissue were assessed as "healthy,"not the macerated wound edges and periwound [DIAGNOSES REDACTED] assessed by the nurse the previous night. The left buttock was assessed as denuded. No measurements were taken. The wound edges and surrounding tissues were assessed as healthy. Review of the 11/18/11 Focus Note documented by the Wound Nurse, indicated that Resident #11 had a stage II pressure ulcer. The Wound Nurse cleaned the wound site, and wound gel and collagen were applied with a perma foam dressing. This treatment was applied without a physician order. There were no recommendations documented on 11/18/11 as to the frequency of the wound treatment and no documented evidence that the pressure ulcer treatment recommendations were communicated to the physician. There were no treatment orders obtained. The Wound Team Leader and Unit Manager #3 reviewed the Treatment Administration Record (TAR) and physician orders [REDACTED].M. and said that the resident never received the coccyx wound treatment recommended by the Wound Nurse on 11/18/11, because no one contacted the physician for a physician's orders [REDACTED]. Review of the TAR on 11/19/11 indicated that the resident only received Dimethicone, a barrier cream, to the left buttock and coccyx on all three shifts. No treatment was provided to promote healing of the open pressure area. On 11/20/11, the 7-3 shift nurse documented a deterioration in the wound status. "Areas to the coccyx open. Red center with minimal slough, positive bleeding. Size of dime. Positive foul smell. Smaller area to the right of coccyx superficial pink." The Nurse Practitioner was notified. The Nurse Practitioner examined the resident on 11/20/11. Assessment by the Nurse Practitioner indicated that the resident had a sudden temperature elevation the previous evening of 101.8. The Nurse Practitioner assessed the resident as asymptomatic for active disease and documented that the resident had "detection of [DIAGNOSES REDACTED]tous, coccygeal wound described as foul smelling with yellow slough." A wound culture, urine culture and blood work was ordered. On 11/21/11, the Nurse Practioner transferred the resident to the hospital. The resident was hospitalized from [DATE] until 11/25/11 for treatment of [REDACTED]. On 11/25/11 at 3:30 P.M., the Admission nursing assessment indicated a body diagram that identified an "open area" on the buttocks and an "ulcer" on the coccyx. The nurse documented: "patient has stage 2 pressure ulcer on coccyx - (treatment) in place." New wound treatment orders dated 11/25/11 for the coccyx wound included, to cleanse the area with normal saline, apply Santyl ([MEDICATION NAME] agent) followed by a dry protective dressing to be completed every shift. The left buttock treatment included, a normal saline wash, apply hydrogel followed by collagen and dry protective dressing to be completed each shift. On 11/25/11, the day the resident returned to the facility, the wound culture reported to the facility indicated that the resident's coccyx wound was infected with "heavy growth" staphylococcus aureus and heavy growth diptheroids. (infection of the coccyx wound) There was no documentation that this information was communicated to the physician. Review of the TAR from 11/25/11 through 11/27/11 indicated that the coccyx and buttock wounds were treated, however the areas were not assessed for size, depth, drainage and odor. The Wound Team Leader and Unit Manager #3 said on 11/30/11 at 9:30 A.M., that the TAR indicated that Resident #11's coccyx and left buttock wound were treated with Dimethicone, a barrier cream, from 11/25/11 through the 7-3 shift on 11/29/11. The Wound Team Leader and Unit Manager #3 were unable to explain why staff would continue to use Dimethicone on open wounds. The Wound Team Leader and Unit Manager #3 said that the TAR also indicated new wound treatment orders following the resident's readmission on 11/25/11, but were unable to explain which wound treatment that resident had received. The facility also failed to provide adequate pressure relief. Although the resident developed pressure areas, the resident was not provided with a pressure relieving mattress. Review of the skin care plan dated 11/14/11, stated to turn and reposition the resident every 2 hours, but each time the resident was observed, the resident was lying on his/her back. During initial tour on 11/29/11 at approximately 10:25 A.M., on 11/29/11 at 2:25 PM and on 11/30/11 at 8:35 A.M., Resident #11 was observed lying in bed on his/her back with the head of the bed elevated. Review of the 11/30/11 Wound Team assessment provided on 12/5/11 indicated that Resident #11's coccyx wound had deteriorated and increased in size. The coccyx wound measured (length) 1.6 cm x (width) 1.4 cm x (depth) 0.1 cm. with evidence of inflammation of the wound edges and surrounding tissues. The 11/30/11 assessment also indicated deterioration in the buttock wound with inflammation noted on the wound edges and surrounding tissue. There was no documentation that the facility addressed the decline in the wound(s) or communicated these changes to the physician. The Wound Team Leader was asked on 11/30/11 at approximately 8:45 AM, how other disciplines are notified about skin changes or new pressure ulcers and was told that the discussion would take place at Risk/Nutrition Meetings. The Wound Team Leader said a meeting had taken place on 11/28/11. Per request, a copy of a Skin Committee meeting held 11/28/11 was provided. Review of the "meeting notes contained signatures of the attendees. The Notes section only listed Resident #11's name, "new admission" stage II coccyx. No other information was documented such as deterioration of the wound or evidence of infection. The facility Dietician was interviewed on 11/30/11 at 10:30 A.M., said that a Risk/Nutrition meeting had taken place on 11/28/11. The Dietician said that there was no discussion about the Resident #11's pressure areas. The Dietician said that she was unaware that the resident had developed a stage II pressure area on 11/18/11 and had she known, she would have considered increasing the resident's protein intake to assist with wound healing. On 12/1/11 at 10:00 A.M. the surveyor(s) conducted a scheduled wound care observation. Treatment Nurse #1 said that the current orders, dated 11/25/11 for the coccyx, was to the cleanse the wound with normal saline and apply Santyl followed by a dry protective dressing. The left buttock wound care included to cleanse the area with normal saline wash and apply hydrogel and dry protective dressing. Treatment Nurse #1 said that the resident was medicated with Tylenol approximately 45 minutes prior to the initiation of the treatment. Treatment Nurse #1 said that the resident's previous wound dressings were removed and discarded due to bowel incontinence. Observation of the left buttock revealed an open wound with defined rolled and reddened wound edges. The periwound was reddened and inflamed. The coccyx was observed as a round dime size wound with depth. The entire wound bed was covered with yellow slough (necrotic tissue). The wound edges and surrounding tissues were inflamed and reddened. The resident complained of being "uncomfortable" by mouthing the word uncomfortable during the wound treatment. Treatment Nurse #1 said that the resident's complaints about pain during wound care were new and would be addressed with the physician. Unit Manager #3, who was interviewed on 12/1/11 at 10:30 A.M., was unable to answer if the wound status had improved or declined as she had not observed the wound. Unit Manager #3 stated that she would notify the physician regarding the decline in the wound and increased pain. On 12/5/11 at 4:00 P.M., the Wound Team Leader said that the Wound Team made no recommendations for changes in wound management on 11/30/11 even though both of Resident #11's wounds were assessed as deteriorated and a culture of the coccyx wound completed on 11/25/11 was positive for a wound infection. There was no documented evidence that the physician was notified of the deterioration of the resident's 2 pressure areas. On 12/5/11 the surveyor was informed that Resident #11 had developed a fever on 12/4/11 and was transferred to the hospital.